Evaluating the prevalence, nutritional quality, and marketing

characteristics of nutritionally-enhanced foods in Canada

by

Sheida Noorhosseini

A thesis submitted in conformity with the requirements

for the degree of Master of Science (M. Sc.)

Graduate Department of Nutritional Sciences

University of Toronto

© Copyright by Sheida Noorhosseini 2016

ii

Evaluating the prevalence, nutritional quality, and marketing

characteristics of nutritionally-enhanced foods in Canada

Sheida Noorhosseini

Master of Science (M.Sc.)

Nutritional Sciences

University of Toronto

2016

Abstract

Nutritionally-enhanced foods are a fast-growing sector of the global food industry. Concerns

have been raised that the consumption of these products may have negative repercussions on

population health, such as high nutrient intakes inappropriate for certain population subgroups

(e.g. children) and the shifting of dietary patterns to include more unhealthy foods. This thesis

aimed to evaluate the prevalence, nutritional quality, and marketing characteristics of foods with

added nutrients in the Canadian market. Many nutritionally-enhanced foods contained high

levels of nutrients beyond recommended intakes, despite these nutrients having no evidence of

inadequacy in the Canadian population. Additionally, a large proportion of foods with added

nutrients had poor nutrient profiles and carried heavy marketing on their labels, regardless of

their nutritional quality. These findings support concerns surrounding the consumption of foods

with added nutrients and suggest the need to further evaluate these concerns by investigating

consumer attitudes and decision-making towards these foods.

iii

Acknowledgements

I would like to express my gratitude to everyone who has helped me on my journey as a Master’s

student. First and foremost, I would like to sincerely thank my supervisor, Dr. Mary L’Abbé. I

came into this program with almost no prior knowledge in nutrition and I have come a long way

thanks to the support and guidance of my supervisor. She has shared with me her knowledge and

wisdom in a way that has not only helped me to write this dissertation and feel like I have

contributed to the research community, but also in a way that has helped me grow as a student, as

a researcher, and as a person to reach where I am today. I would also like to thank her for being a

genuinely kind and caring person who, despite her busy schedule, views her students as her

number one priority and ensures that they receive all the help that they need to succeed.

I am also very grateful for the feedback and support that my thesis advisory committee—Dr.

Heather Boon, Dr. Joanne Arcand, and Dr. Deborah O’Connor—has given me over the course of

my studies, helping me to challenge myself and expand my ideas to improve my work. I would

also like to thank my wonderful labmates: Jodi Bernstein, Mary Scourboutakos, Mahsa Jessri,

Mavra Ahmed, Marie-Eve Labonté, Beatriz Franco, Alyssa Schermel, and Theresa Poon, for

their friendship and invaluable advice. Finally, I am eternally grateful to my family and friends

for giving me their constant support and love.

iv

Table of Contents

Abstract ........................................................................................................................................... ii

Acknowledgements ........................................................................................................................ iii

Table of Contents .......................................................................................................................... iiv

List of Tables ................................................................................................................................ vii

List of Appendices ....................................................................................................................... viii

List of Abbreviations .................................................................................................................... iix

Chapter 1 ....................................................................................................................................... 1

1 - Introduction ........................................................................................................................... 1

1.1 Overall rationale................................................................................................................ 1

Chapter 2 ....................................................................................................................................... 3

2 - Literature review ................................................................................................................. 3

2.1 Regulatory history of the addition of nutrients to foods in Canada .................................. 3

2.1.1. Mandatory and voluntary fortification ...................................................................... 3

2.1.2. Discretionary fortification ......................................................................................... 4

2.1.3. “Food-like” natural health products .......................................................................... 5

2.1.4. Transition of food-like natural health products to the food regulatory framework .. 6

2.1.5. Supplemented foods and functional foods ................................................................ 6

2.2 Prevalence of nutritionally-enhanced foods ...................................................................... 7

2.2.1 Voluntarily fortified foods ......................................................................................... 7

2.2.2. Supplemented and functional foods .......................................................................... 7

2.3 Nutrition marketing on food labels of nutritionally-enhanced foods ................................ 8

2.3.1. What is nutrition marketing? .................................................................................... 8

2.3.1.1. Nutrient content claims ...................................................................................... 9

2.3.1.2. Health Claims..................................................................................................... 9

2.3.1.3. Front-of-pack (FOP) labelling ......................................................................... 11

2.3.2. Influence of nutrition marketing on consumer attitudes ......................................... 12

2.3.3. Prevalence of nutrition marketing on prepackaged foods with added nutrients ..... 13

v

2.4 Nutrient profiling of nutritionally-enhanced foods ......................................................... 13

2.4.1 What is nutrient profiling? ....................................................................................... 13

2.4.2 FSANZ Nutrient Profiling Scoring Criterion (NPSC) ............................................. 14

2.4.2.1. Overview of FSANZ Nutrient Profiling Model (NPSC) ................................. 15

2.4.3 The nutritional quality of nutritionally-enhanced foods .......................................... 17

2.5 Concerns surrounding nutritionally-enhanced foods ...................................................... 18

2.6 Scope and objectives of thesis ........................................................................................ 20

Chapter 3 ..................................................................................................................................... 22

3 - Study 1: The prevalence, nutritional quality, and marketing characteristics of

supplemented foods and functional foods in the Canadian marketplace .................................. 22

3.1 Abstract ........................................................................................................................... 23

3.2 Introduction ..................................................................................................................... 23

3.3 Methodology ................................................................................................................... 25

3.3.1 Data collection ......................................................................................................... 25

3.3.2 Data analysis ............................................................................................................ 26

3.4 Results ............................................................................................................................. 29

3.5 Discussion ....................................................................................................................... 52

Chapter 4 ..................................................................................................................................... 58

4 – Study 2: The nature and prevalence of voluntarily fortified foods with high levels of added

vitamins and minerals in the Canadian marketplace ................................................................. 58

4.1 Abstract ........................................................................................................................... 58

4.2 Introduction ..................................................................................................................... 59

4.3 Methodology ................................................................................................................... 60

4.3.1 Data collection ......................................................................................................... 60

4.3.2 Data analysis ............................................................................................................ 61

4.4 Results ............................................................................................................................. 62

4.3 Discussion ....................................................................................................................... 73

Chapter 5 ..................................................................................................................................... 77

5 - General Discussion .............................................................................................................. 77

vi

5.1 Overview of findings ...................................................................................................... 77

5.2 General discussion .......................................................................................................... 79

5.3 Conclusion ...................................................................................................................... 84

References ..................................................................................................................................... 86

Appendices .................................................................................................................................... 94

vii

List of Tables

Table 1. Prevalence of supplemented foods* (SFs) in the Canadian marketplace in 2013 ......... 33

Table 2. Levels of added vitamins and minerals in the most common supplemented food*(SF)

categories .............................................................................................................................. 34

Table 3. Added caffeine and amino acids in supplemented foods* (SFs) in Canada in 2013 ..... 36

Table 4. Prevalence of functional foods* (FFs) in the Canadian marketplace in 2013 by food

subcategory ........................................................................................................................... 37

Table 5. Ingredients added to functional foods in the Canadian food market in 2013 ................ 39

Table 6. Comparison of NPSC nutrient profile scores* of supplemented foods¥ (SFs) and non-

supplemented foods (non-SFs) in the Canadian marketplace in 2013 .................................. 40

Table 7. Number and proportion of SFs* and non-SFs meeting ‘healthy’ cutpoints based on the

FSANZ NPSC system¥ ......................................................................................................... 41

Table 8. NPSC nutrient profile scores* of functional foods¥ (FFs) and non-functional foods

(non-FFs) in the Canadian marketplace in 2013 ................................................................... 42

Table 9. Number and proportion of FFs* and non-FFs meeting ‘healthy’ cutpoints based on the

FSANZ NPSC system¥ ......................................................................................................... 44

Table 10. Breakdown of NPSC scores¥ of functional foods (FFs)ǂ compared to non-functional

foods (non-FFs) per food subcategory .................................................................................. 45

Table 11. Level of nutrition marketing on food labels of supplemented foods* (SFs) and non-

supplemented foods (non-SFs) in Canada in 2013 ............................................................... 49

Table 12. Level of nutrition marketing on food labels of functional foods* (FFs) and non-

functional foods (non-FFs) in Canada in 2013 ..................................................................... 50

Table 13. The prevalence of voluntarily fortified foods with high levels of added vitamins and

minerals (VHVMs) in the Canadian market in 2013 ............................................................ 65

Table 14. Vitamins and minerals present in VHVMs* in the Canadian market in 2013 ............. 67

Table 15. Comparison of FSANZ nutrient profiling scores* of VHVMs¥ and non-VHVMs in

Canada in 2013. .................................................................................................................... 68

Table 16. Number and proportion of VHVMs* and non-VHVMs meeting ‘healthy’ cutpoints

based on the FSANZ NPSC system¥. ................................................................................... 70

Table 17. Levels of nutrition marketing on VHVMs* compared to non-VHVMs in Canada in

2013....................................................................................................................................... 71

viii

List of Appendices

Appendix 1. Method for calculating FVNL content of foods using the Ingredients List ............ 94

Appendix 2. Ingredients that can be added to nutritionally-enhanced foods ............................... 95

Appendix 3. List of all supplemented foods (SFs) and ingredients in the FLIP 2013 ................. 97

Appendix 4. Standardized method used to calculate FSANZ nutrient profiling score (NPSC)

using data in the Canadian FLIP 2013 database ................................................................. 102

ix

List of Abbreviations

AI – Adequate Intake

AMDR – Acceptable Macronutrient Distribution Range

CCHS – Canadian Community Health Survey

CFIA – Canadian Food Inspection Agency

CNF – Canadian Nutrient File

DRRC – Disease Risk Reduction Claim

DV – Daily Value

FDR – Food and Drug Regulations

FF- Functional Food

FLIP – Food Label Information Program

FOP – Front-of-Pack

FSANZ – Food Standards Australia New Zealand

FVNL – Fruit/vegetable/nut/legume

NCD – Non-communicable diseases

NFt – Nutrition Facts Table

NHP – Natural Health Product

NHPR – Natural Health Products Regulations

NPSC – Nutrient Profiling Scoring Criterion

RDA- Recommended Daily Allowance

RTE – Ready-to-Eat

SF – Supplemented Food

TMA – Temporary Marketing Authorization

x

TMAL – Temporary Marketing Authorization Letter

UL – Tolerable Upper Level

USA – United States of America

VHVM – Voluntarily fortified foods with high levels of vitamins and minerals

1

Chapter 1

1 - Introduction

1.1 Overall rationale

As national and global rates of obesity and diet-related noncommunicable diseases (NCDs)

continue to rise (1, 2), consumers worldwide are becoming more aware of the relationship

between diet and health and are demanding more foods and beverages with nutritional

enhancements that are beneficial to physical and mental well-being (3, 4). In Canada, this has led

to the proliferation of foods containing added vitamins, minerals, herbals, bioactives, amino

acids, novel fibres, and other substances in the food market. Depending on the type and amount

of substances that are added, these foods are referred to as supplemented foods (SFs), functional

foods (FFs), or foods with voluntary additions of high levels of vitamins and minerals (VHVMs).

Researchers and health professionals have raised concerns that the use of these products may

have detrimental effects on population health. If consumers perceive SFs, FFs, and VHVMs as

healthier due to their added ingredients—particularly if they are heavily marketed—without

considering other nutritional aspects (e.g. sugar, fat, or sodium content) of the food, they may

inadvertently make unhealthy dietary choices and negatively impact their eating patterns. In

addition, the consumption of foods with added vitamins, minerals, and other micronutrients,

especially in combination with supplement use, may lead to excessive intakes that exceed Upper

Levels (ULs) and/or are not appropriate in certain population subgroups, such as children and

adolescents (5).

There is currently a lack of data on the prevalence and nature of nutritionally-enhanced foods in

Canada. Therefore, the objective of this thesis was to examine and evaluate the frequency,

nutritional quality and marketing characteristics of SFs, FFs, and VHVMs in the Canadian

market in 2013 using the University of Toronto Food Label Information Program (FLIP) 2013, a

food database containing information on over 15,000 foods and beverages sold in major

Canadian grocery stores. In Study 1, the prevalence and nature of SFs and FFs were evaluated.

2

In Part I of this study, the frequency and proportion of SFs and FFs in each food category, and

the type and/or amount of added nutrients in SFs and FFs was assessed. In Part II of this study,

the nutritional quality of SFs and FFs was determined using a validated nutrient profiling model.

Nutrient profile scores were then compared between foods with added supplemental or

functional ingredients and comparable conventional foods without these additions. The number

of nutrition-related claims occurring on food labels of SFs and FFs was also examined. Study 2

specifically examined foods with high levels of voluntary addition of vitamins and minerals. The

frequency of VHVMs and the types of foods that were most likely to contain high levels of

vitamins and minerals added through voluntary fortification were determined. Additionally, the

nutrient profile scores and number of nutrition-related claims were compared between VHVMs

and foods that did not contain high levels of voluntary fortification. The findings of this thesis

provides baseline data on nutritionally-enhanced foods in Canada and can help formulate future

research examining the consumption patterns of these foods in the Canadian population and

possible areas where policy or regulatory changes may be needed to address these concerns

surrounding the availability and use of these foods.

3

Chapter 2

2 - Literature review

2.1 Regulatory history of the addition of nutrients to foods in Canada

2.1.1. Mandatory and voluntary fortification

Vitamin deficiency as a cause of disease was first observed in Canada in the early 1900s in

segments of the population with beriberi and blindness in Newfoundland and Labrador (6). Since

this discovery and additional documentations of vitamin deficiency across the country, the

Canadian government has implemented the fortification of foods with vitamins and minerals as a

method to address and eliminate these deficiencies and the illnesses associated with them.

Synthetic vitamins first became available for addition to foods with no restrictions in the 1930s

and 1940s (7). As many of these foods began to carry nutrition related claims that were deemed

to be exaggerated and misleading, concern about fraudulent practices prompted the Canadian

government to enforce regulations in 1941 restricting the types of claims that could appear on

products, and minimum and maximum levels of vitamin addition were introduced in 1942 and

1949 respectively (7). In the 1940s and 1950s, the addition of iodine to salt essentially eliminated

the condition of goiter in Canada, and vitamin D fortification was used to address the high

incidence of rickets throughout the country (7). In the case of vitamin D, a survey conducted in

Ontario in 1963 suggested that children had very high daily intakes of vitamin D due to a

combination of a variety of fortified foods and supplements (8). This led to a change in

regulations prohibiting the addition of vitamin D to most food products, and inadvertently

resulted in an increase in the incidence of rickets (8, 9). Experiences with vitamin D fortification

prompted Health Canada to create a “positive listing” approach to food fortification in the

updated regulatory provisions made in 1964 (7). The Food and Drug Regulations (FDR) include

a list of foods that must be fortified with vitamins, minerals or amino acids at specified levels,

and prohibits the addition of a micronutrient to foods that is not included in this list or in an

amount that falls outside the specified range for a particular nutrient (10). Under current

4

regulations, nutrients may be added to foods in Canada for purposes consistent with the Codex

General Principles for the Addition of Essential Nutrients to Foods, including: “i)

preventing/reducing the risk of, or correcting, a demonstrated deficiency of one or more essential

nutrients in the population; ii) reducing the risk of, or correcting, inadequate nutritional status or

intakes of one or more essential nutrients in the population; iii) meeting requirements and/or

recommended intakes of one or more essential nutrients; iv) maintaining or improving health;

and/or v) maintaining or improving the nutritional quality of foods” (11).

This approach to food fortification is regarded by Health Canada as a successful fortification

program that both ensures the prevention of nutrient inadequacies and protects against excessive

nutrient intakes in the population (7, 9).

In addition to the mandatory fortification of certain foods—for example the addition of vitamins

A and D to margarine—the addition of vitamins and/or minerals is optional or “voluntary” for

certain other foods. An example of voluntary fortification includes the addition of B vitamins to

breakfast cereals. As with mandatory fortification, voluntary fortification permits the voluntary

addition of micronutrients so long as they comply with the type and amount set out in the FDR

(10).

2.1.2. Discretionary fortification

From 1998 to 2005, Health Canada began a series of consultations to review its food fortification

policies. This process was initiated in response to concerns that the policies regarding the

addition of vitamins and minerals to foods in Canada were too restrictive and limited the

development of new food products and the opportunity to provide Canadians with a wider

variety of fortified food choices (7). After a lengthy and multifaceted process, draft regulations

were published in 2005 in the Addition of Vitamins and Minerals to Food, 2005: Health

Canada’s Proposed Policy and Implementation Plan (12). The proposed policy recommended

the expansion of fortification programs to allow for the addition of vitamins and minerals to

foods at the discretion of the manufacturer for the purposes of meeting recommended intakes and

reducing the risk of inadequate nutritional status in the Canadian population (12). By 2009, the

5

Minister of Health rejected this proposal due to conflicting stakeholder concerns (13). Health

stakeholders were wary of the potential spread of fortified foods with otherwise substandard

nutritional value and the appearance of claims on these products that could mislead consumers to

make unhealthy dietary choices. On the other hand, the food industry was concerned that the

proposed policies were too inflexible and were not on par with the fortification policies of other

countries, creating barriers to food innovation (13). Due to these concerns, Health Canada began

to review alternative approaches to revising the original fortification principles and create

regulations that allow for a greater variety of foods to contain added nutrients in a safe manner.

As of 2015, Health Canada has not yet published a document on its revised and finalized policies

or regulatory amendments, although several policy documents regarding foods that had been

marketed as natural health products have been released (see 2.1.3).

2.1.3. “Food-like” natural health products

With the stalling of discretionary fortification regulatory changes, food industry manufacturers

sought faster market access for foods with added micronutrients that were not in compliance with

the FDR through the Natural Health Products Regulations (NHPR) (13). The NHPR came into

effect in 2004 to oversee the safety, efficacy and quality of a class of products referred to as

natural health products (NHPs) (14). A NHP is characterized as a substance or combination of

substances set out in Schedule 1 of the NHPR, that is intended to be used either in the diagnosis,

treatment, or prevention of a disease, restoring or correcting biological functions, or to promote and

maintain good health, and includes vitamin and mineral supplements, probiotics, herbal remedies,

homeopathic medicines, traditional Chinese medicines, and other products such as essential fatty

acids and amino acids (14). Although the NHPR was not designed to regulate conventional food

products, as specified in the Regulatory Impact Analysis Statement, NHPs in food format were

not excluded from the scope of the regulations (15). Foods, such as energy drinks, with high

levels of added vitamins, minerals, amino acids, herbals, bioactives and other nutrients that are

not permitted or are in amounts that are greater than what is permitted for addition to foods under

the FDR were able to gain access to the Canadian market as NHPs under the NHPR (13). Several

hundred foods with added micronutrients have since gained market access as NHPs (13).

6

2.1.4. Transition of food-like natural health products to the food regulatory

framework

In 2010, Health Canada came to the realization that certain NHPs in food format were being

marketed and used as foods, rather than products intended for therapeutic purposes (13). As a

result, Health Canada published a guidance document (16) to assist regulators in determining

whether or not a product in food format should be classified as a NHP. Revised classification

decisions are based on a series of criteria that distinguish NHPs from foods outlined in the

document (16). For instance, if a product has similar product packaging as a typical food, is

perceived by the public as a food rather than a therapeutic product, and has a historical pattern of

use as a food, then it must now be classified as a food, not an NHP (16). In 2011, Health Canada

began a phased approach—beginning with caffeinated energy drinks (CEDs), followed by

additional food categories—to transition several hundred misclassified products sold under the

NHPR back to the food regulatory framework (13). The transition process was facilitated

through the issuance of Temporary Marketing Authorization Letters (TMALs). Temporary

Marketing Authorization (TMA) allows products that contain an ingredient that is prohibited

under the FDR, but has no immediate safety concerns, to gain market access for a specified

period of time, usually for 2 to 5 years (17). During this time, industry is required to provide

research addressing data gaps and collect the information necessary to create appropriate

regulatory policies and manage potential health risks that are associated with the consumption of

these foods (17). Category specific guidance documents were created to outline the scope and

eligibility of products that could receive TMALs (18, 19). The transition process was completed

in December 2012 (13).

2.1.5. Supplemented foods and functional foods

In the guidance documents for obtaining TMALs, Health Canada refers to a subset of foods as

supplemented foods (18, 19). A supplemented food has been broadly defined as: “a pre-packaged

product that is manufactured, sold or represented as a food, which contains added vitamins,

minerals, amino acids, herbal or bioactive ingredients” which “may perform a physiological role

beyond the provision of nutritive requirements”(20). According to this definition, a

supplemented food would not include foods containing added nutrients in amounts that are

7

permissible for fortification, enrichment, or food additive purposes according to the FDR (20).

Certain public health groups, including Dietitians of Canada, have voiced concerns, such as a

lack of clarity, regarding Health Canada’s proposed definition of a supplemented food (5).

Health Canada has defined a functional food as a food that “is similar in appearance to, or may

be, a conventional food, is consumed as part of a usual diet, and is demonstrated to have

physiological benefits and/or reduce the risk of chronic disease beyond basic nutritional

functions” (21). Some examples of functional foods are foods containing pro- and prebiotics,

phytosterols, novel fibres, protein isolates, omega-3 and omega-6 fatty acids, and other bioactive

substances (21). However, there is currently no strict, regulatory definition of a functional food

or inclusive list of ingredients that are classified as being functional in Canada. From a

regulatory perspective, functional foods are classified as, and included in the same regulatory

framework as conventional foods (22).

2.2 Prevalence of nutritionally-enhanced foods

2.2.1 Voluntarily fortified foods

Voluntarily fortified foods have been shown to greatly contribute to the population intakes of

certain micronutrients, such as iron, in Europe (23). A 2008-2010 survey in Ireland found that

82% of adults reported consuming voluntarily fortified foods, along with more than a 170%

increase in the supply of fortified foods from 1997-1999 to 2008-2010 (24). A study conducted

in the US collected up to two 24-hour dietary recalls per individual on over 8,000 participants

and found that nearly 50% of participants consumed a voluntarily fortified food on either recall

day (25). Although there has been research on the consumption of voluntarily fortified foods

globally, this topic has not yet been investigated in Canada. Additionally, there is a lack of

research on the occurrence of voluntarily fortified foods in Canadian marketplace.

2.2.2. Supplemented and functional foods

There is currently no global definition of a supplemented food or a functional food. As a result,

studies report various results on the prevalence of these foods in the marketplace, since the

8

inclusion and exclusion criteria to define foods as supplemented or functional differ between

studies. However, researchers agree that the nutritionally-enhanced food market is growing

worldwide (26). The global market value of functional foods is estimated to be over USD

61billion (27). In 2013, Japan had the world’s largest market for functional foods, followed by

the USA (27). In Canada, it was reported that the functional food market created a total annual

revenue of over $6 billion in 2011 (28). An analysis conducted on NHPs sold in Canadian

grocery stores between 2010 and 2011 found a total of 66 beverages classified as caffeinated

energy drinks, nutrient-enhanced water beverages, or nutrient-enhanced fruit beverages (29).

Although supplemented foods under current regulations are no longer defined as NHPs, some,

though not all, of the beverages analyzed in the latter study have since been issued TMAs and are

now being sold as supplemented foods (29, 30). Therefore, although the results of this study (29)

can be used to give a snapshot of the number of beverages with added vitamins and minerals on

the Canadian market in 2011, there is virtually no information on the occurrence of

supplemented and functional foods that are currently being sold in Canadian supermarkets.

2.3 Nutrition marketing on food labels of nutritionally-enhanced foods

2.3.1. What is nutrition marketing?

Food manufacturers may employ certain types of nutrition marketing on food labels, such as

nutrient content claims, health claims, and Front-of-Pack (FOP) labelling systems, to

communicate the nutritional content of their foods to consumers. Nutrition marketing has been

defined as any form of marketing of food or beverage products that employs health or nutrition

information that is outside the scope of minimum requirements (31). The minimum food

labelling requirement on most prepackaged foods in Canada is the Nutrition Facts Table (NFt),

which contains information on the serving size, energy value, and nutrient values of thirteen core

nutrients (10). Therefore, any health or nutrition information outside of the NFt can be

considered as nutrition marketing. This includes nutrient content claims, health claims, and

Front-of-Pack (FOP) labelling (32). These forms of nutrition marketing are all considered as

voluntary labelling (32). From a Health Canada regulatory perspective, the principal objective of

all forms of nutrition marketing is to aid consumers in making informed dietary choices to

reduce the risk of injury to health (33). However, others have argued that nutrition marketing is

9

yet another form of marketing by food companies driven by motives to increase sales rather than

benefit consumer health (34).

2.3.1.1. Nutrient content claims

Nutrient content claims are described by the FDR as “statements or expressions which describe,

directly or indirectly, the level of a nutrient or energy in a food or a group of foods” (10). The

FDR has defined a list of compliant nutrient content claim categories, such as dietary fibre

claims, and laid out a specific set of compositional requirements that must be met for each

specific claim within each category. For example, to make a “source of” claim regarding the

vitamin or mineral content of a food, the food must contain a minimum of 5% of the labelling

Daily Value (DV) of the vitamin or mineral. Some other examples of nutrient content claims

include “high in fibre”, “low in energy”, and “no added sugar” (10).

In this study, highly fortified foods were classified as foods containing added vitamins and

minerals in an amount that is greater than 25% of the DV for that vitamin or mineral. With the

exception of vitamin C, a nutrient content of at least 25% of the DV is the minimum amount

required to make an “excellent source of” nutrient content claim regarding a vitamin or mineral

in foods and beverages under Canadian regulations. Foods containing vitamin C require twice

that amount to make the same claim (10).

2.3.1.2. Health Claims

The FDR defines a health claim as “any representation in labelling or advertising that states,

suggests, or implies that a relationship exists between the consumption of a food and health”

(10). There are several different types of health claims and each type of claim has its own set of

regulations. The types of health claims include disease risk reduction claims (DRRC),

therapeutic claims, function claims, nutrient function claims, probiotic claims, general health

claims (32).

Disease risk reduction claims “link a food to a reduced risk of developing a diet-related disease

or condition in the context of the total diet” (10). There are currently five categories of disease

risk reduction claims that are permissible and the conditions to be met for making each

prescribed statement can be found in the Disease Risk Reduction Claims Table in the FDR (10).

10

A list of assessments for additional, more recently approved DRRCs, can be found on the Health

Canada website (35). An example of a disease risk reduction claim is: “A healthy diet rich in a

variety of vegetables and fruit may help reduce the risk of some types of cancer” (10). A

therapeutic claim relates to treating or alleviating a disease or health condition, or improving or

altering bodily functions (10). An example of a therapeutic claim is: “Oat fibre helps reduce

cholesterol” (10). Disease risk reduction claims and therapeutic claims are subject to pre-market

assessment by the Food Directorate of Health Canada (32). Only claims that have been

substantiated by rigorous scientific evidence are permitted. Details of the submission

requirements for substantiation of health claims have been published and updated regularly (36).

Function claims describe the effects that the consumption of a food has on regular body

functions (10). There are two subcategories of function claims: nutrient function claims and

probiotic claims (32). Nutrient function claims describe the role of energy or a particular nutrient

in a food in promoting normal body function or maintaining good health (10). An example of a

nutrient function claim is: “Protein helps build and repair body tissues” (10). Most nutrient

function claims require minimum amounts of the nutrient to be present, such as vitamin and

mineral nutrient function claims (10). However, some nutrient function claims, such as claims

relating to omega-3 or omega-6 fatty acids, do not require a minimum amount of nutrient to be

present in order to make the claim (10). However, in all cases, the amount of nutrient present in

the food must be stated in either the NFt or in a quantitative statement elsewhere on the food

label. Probiotic function claims are claims regarding the health benefits of microorganisms

present in a food and can be either strain-specific or non-strain-specific claims (32). Although

function claims must act in compliance with subsection 5.1 of the Canadian Food and Drugs Act

(FDA), which dictates that no claim shall be made that is “false, misleading, or deceptive” (37),

they do not require pre-market assessment by Health Canada (32). Instead, the Canadian Food

Inspection Agency has created the Industry Labelling Tool (32) to act as a reference to aid

industry in meeting certain scientific standards should they be asked by the CFIA to provide

evidence to substantiate a claim. In addition, Health Canada has published a Guidance Document

(38) to create guidelines on the addition of probiotics to food, such as setting a minimum amount

of probiotics that must be present in a food to make a probiotic function claim.

11

Finally, general health claims are defined as “broad claims that promote health through healthy

eating or that provide dietary guidance” (32). General health claims do not make reference to

health effects, diseases, or other health conditions. An example of a general health claim is a

weight maintenance claim, such as the following statement: “As part of healthy eating, this food

may assist in maintaining a healthy body weight because it is portion controlled” (10). Similar to

function claims, general health claims are not subject to pre-market assessment (32). Aside from

having to abide with subsection 5.1 of the FDA, which, as previously stated, dictates that no

claim may be “false, misleading, or deceptive” (37), general health claims do not fall under any

category-specific regulations. Industry is expected to follow guidelines provided by the CFIA

(32) in formulating general health claims.

2.3.1.3. Front-of-pack (FOP) labelling

In addition to nutrient content and health claims, front-of-pack (FOP) nutrition rating systems

and symbols are another form of nutrition marketing. FOP systems (FOPS) provide a snapshot of

the nutritional content and characteristics of a food or beverage, often consolidating different

dietary aspects of the food into a single visual representation (39). FOP labelling most often

appears on the principal display panel of a product, but may also appear on other panels (39).

The underlying purpose of most FOPS is to give consumers the ability to quickly compare foods

and make healthier choices (39).

Unlike nutrient content claims and health claims, FOP labelling is currently not subject to

specific regulations in Canada. Manufacturers may opt to pay an additional licensing fee to

display third-party FOP symbols or they may choose to create their own symbols (40). Some

examples of FOP systems created by industry are President’s Choice® Blue Menu® and Kraft®

Sensible Solutions™. Since there are currently no specific regulations in place restricting the use

of FOP systems and symbols on prepackaged foods in Canada, there are no standardized

nutrition criteria that are used to assess whether or not a food may include FOP labelling. As a

result, nutrition criteria vary widely and conflict between different FOP programs (39).

12

2.3.2. Influence of nutrition marketing on consumer attitudes

Recent studies in Canada have found that consumers form more positive attitudes—including

higher ratings of healthfulness and greater intent to purchase—towards prepackaged products

containing regulated nutrition-related claims (i.e. nutrient content claims or health claims) than

products that do not carry these claims (41, 42). In a 2013 study conducted in Canada (41), three

sodium claims—an approved disease risk reduction claim, a fictitious function claim, and an

approved nutrient content claim—were tested against a control claim (related to taste) in a mock

package experiment. Participants viewed each mock package and were given surveys to

complete to evaluate their attitudes toward the product. The mock package in each condition had

identical nutrient profiles and participants were provided with a Nutrition Facts table to view the

accurate nutritional information for each package. Results found that all three sodium claim

conditions—regardless of the type of claim—resulted in consumers having more positive

attitudes towards the product, and giving higher ratings of overall healthfulness and having

greater intent to purchase the product than the control condition.

Outside of Canada, studies have found variable results on the effects of nutrition marketing on

the attitudes of consumers. Generally, however, studies from Europe and the US have found that

consumers view nutrient content and health claims as useful and that consumers have more

positive attitudes towards the nutritional value of a food if it features a nutrient content or health

claim (43-46). It has also been found that the presence of a health claim on a product can result

in a general “halo” effect, causing the consumer to favourably view other nutritional attributes of

the food that are unrelated to the health claim (42). However, certain studies, such as a review

conducted by the European Food Information Council, have found that the overall attitude of

consumers towards a product may not necessarily improve with the addition of a health claim,

but may also depend on various factors such as food category and consumer variables, such as

familiarity with the claim and nutrition knowledge (42, 47).

In the case of FOP labelling, since there is currently no standardized FOP system and there are a

wide range of FOP systems, comparisons cannot be made between every potential FOP system

and all the other systems. However, studies have suggested that consumers tend to view products

with certain types of FOPS as being healthier than products that lack these systems (48-50). For

example, in a US study conducted in 2011 (50), a mock-package carrying a FOP system (i.e.

13

Smart Choices) was tested against a control mock-package carrying no FOP label. The mock-

package product used in both conditions in this study was a product that met the nutritional

criteria for carrying the Smart Choices icon, yet contained high amounts (i.e. 20% of the Daily

Value) of sodium and cholesterol. Study participants were given surveys to rate the overall

healthfulness of products, amongst other measures. Participants gave the mock-package carrying

the Smart Choices icon a significantly higher overall healthfulness rating and perceived the

product as having a significantly lower amount of sodium than the control mock-package with no

FOP icon. These types of findings suggest that consumers may prefer products carrying FOP

marketing as opposed to products lacking these systems.

2.3.3. Prevalence of nutrition marketing on prepackaged foods with added nutrients

A cross-sectional analysis conducted on a 2010 food database containing over 10,000

prepackaged foods sold in supermarkets in Canada found that 48.1% of food packages carry

some form of nutrition marketing (51). The most common type of claim was nutrient content

claims, followed by FOP labelling. Disease risk reduction claims were the least prevalent type of

claim, with only 1.7% of products carrying these claims. There has been some research

examining the marketing on the labels of energy drinks and other enhanced beverages sold in

Canada, finding that these beverages carried traditional forms of marketing, such as source and

function claims, in addition to claims highlighting physical performance and mental well-being

(29). However, there has been little research examining the nutrition marketing that occurs on

other nutritionally-enhanced foods such as voluntarily fortified, functional, and other

supplemented foods, and how the amount of marketing on these foods compares to general

foods.

2.4 Nutrient profiling of nutritionally-enhanced foods

2.4.1 What is nutrient profiling?

Nutrient profiling is defined as “the science of classifying or ranking foods according to their

nutritional composition for reasons related to preventing disease and promoting health” (1) and is

commonly used to define foods as ‘healthy’ or ‘unhealthy’ based on the levels of a variety of

14

nutrients in the food (52). Nutrient profiling is one method of evaluating the nutritional quality of

food products and is used in many nutrition policy applications worldwide, including the

regulation of front-of-pack labelling, health and nutrition claims, consumer education, and

restricting the marketing of less healthy foods to children and adolescents (1, 53). There is a

large selection of nutrient-profiling models that have been developed for different applications

by various organizations around the world. The model that was used in this research to evaluate

the healthfulness of foods with added nutrients is the Nutrient Profiling Scoring Criterion

(NPSC) created by Food Standards Australia New Zealand (FSANZ).

2.4.2 FSANZ Nutrient Profiling Scoring Criterion (NPSC)

In January, 2013, Standard 1.2.7 of the Australia New Zealand Food Standards Code was

introduced to govern the regulations of nutrition and health claims on food labels for all foods

sold in Australia and New Zealand (54). FSANZ constructed the Nutrient Profiling Scoring

Criterion (NPSC) system to evaluate an individual food’s healthfulness and eligibility to carry a

claim. In this research, the NPSC was used to compare scores between supplemented and

fortified foods with non-supplemented and non-fortified foods, to determine if there are any

significant differences in the healthfulness of one type of food over the other. The FSANZ model

has several advantages and was therefore chosen as the best model over other nutrient profiling

models for application in this research. First, the FSANZ model is a modified version of the

highly validated Ofcom model (55).The Ofcom model was originally developed by the UK Food

Standards Agency to restrict the advertising of food and drink products to children and has been

rigorously tested, validated, and adapted for various applications around the world (56).

Secondly, the FSANZ model itself has been through numerous stages of development, public

consultations and assessments, and has been tested and validated on over 10,000 foods and

beverages in Australia and New Zealand (1, 57). Third, one of the reasons the FSANZ model

was chosen over the original Ofcom model is that the FSANZ model contains an additional score

threshold for a new food category which includes cheese, edible oils, edible oil spreads, butter

and margarine, foods which were disqualified and not included in the Ofcom model. Since there

are supplemented and functional foods in these food categories, excluding them from the present

analyses would make the analysis in this research less comprehensive. Finally, the UK Ofcom

15

model calculates scores based on per 100 g values on food products, whereas the FSANZ model

uses either per 100 g or per 100 mL values—whichever is declared on the nutrition information

panel—as the basis of its score calculation. Many foods in the database used in this research—

the University of Toronto Food Label Information Program (FLIP)—are declared in volume (i.e.

mL values) on the Canadian nutrition facts tables (NFt) and would not have been easily

converted to gram values. Therefore, for these numerous reasons, the FSANZ model was deemed

to be the most appropriate and efficient model to use as the basis for evaluating the ‘healthiness’

of foods in this research.

2.4.2.1. Overview of FSANZ Nutrient Profiling Model (NPSC)

In the FSANZ nutrient profiling model (NPSC), each food or drink product is allocated into one

of three categories: beverages (Category 1); cheese, edible oil, edible oil spreads, butter and

margarine (Category 3); any food other than those included in categories 1 and 3 (Category 2).

Points are then added towards or deducted for each item according to nutrient content thresholds

for each category. Baseline points are added for nutrients that are associated with a risk of

chronic disease—energy content (kJ), saturated fat (g), total sugars (g) and sodium (mg). Points

are then deducted from the baseline points based on the fruit/vegetable/nut/legume (V), protein

(P) and fibre (F) content of the food. Thus, the final score is calculated with the following

formula:

𝐹𝑖𝑛𝑎𝑙 𝑠𝑐𝑜𝑟𝑒 = 𝑏𝑎𝑠𝑒𝑙𝑖𝑛𝑒 𝑝𝑜𝑖𝑛𝑡𝑠 – (𝑉 𝑝𝑜𝑖𝑛𝑡𝑠) – (𝑃 𝑝𝑜𝑖𝑛𝑡𝑠) – (𝐹 𝑝𝑜𝑖𝑛𝑡𝑠)

Scores fall on a scale between -18 to 81. Food items with lower scores are indicated as being

‘healthier’ than food items with higher scores.

All nutrient content values required to calculate a NPSC score, except for

fruit/vegetable/nut/legume (FVNL) content, are available in the Canadian NFt.

According to the NPSC, a product receives V points depending on the percentage of non-

concentrated and concentrated FVNL the product contains. For products containing only non-

concentrated FVNL, products containing 100%, greater than 80%, greater than 60%, greater than

16

40%, or equal to or less than 40% non-concentrated FVNL receive 8, 5, 2, 1, or 0 points

respectively. For products containing only concentrated FVNL, products containing 100%, at

least 67%, at least 43%, at least 25%, or less than 25% concentrated FVNL receive 8, 5, 2, 1, or

0 points respectively. Products containing a mixture of concentrate and non-concentrated FVNL,

the total percentage of FVNL in the product is calculated according to the following formula:

(% 𝑛𝑜𝑛 − 𝑐𝑜𝑛𝑐𝑒𝑛𝑡𝑟𝑎𝑡𝑒𝑑 𝑓𝑣𝑛𝑙) + (2 𝑥 % 𝑐𝑜𝑛𝑐𝑒𝑛𝑡𝑟𝑎𝑡𝑒𝑑 𝑓𝑟𝑢𝑖𝑡 𝑜𝑟 𝑣𝑒𝑔𝑒𝑡𝑎𝑏𝑙𝑒𝑠)

(% 𝑛𝑜𝑛 − 𝑐𝑜𝑛𝑐𝑒𝑛𝑡𝑟𝑎𝑡𝑒𝑑 𝑓𝑣𝑛𝑙) + (2 𝑥 % 𝑐𝑜𝑛𝑐𝑒𝑛𝑡𝑟𝑎𝑡𝑒𝑑 𝑓𝑟𝑢𝑖𝑡 𝑜𝑟 𝑣𝑒𝑔𝑒𝑡𝑎𝑏𝑙𝑒𝑠) + (% 𝑛𝑜𝑛 𝑓𝑣𝑛𝑙 𝑖𝑛𝑔𝑟𝑒𝑑𝑖𝑒𝑛𝑡) ×

100

1

As quantitative declarations of the quantity of food ingredients are not required to be labelled in

Canada, an in-house algorithm created by members of the L’Abbé Lab at the University of

Toronto was used to calculate the FVNL content of a food based on the position of an ingredient

in the Ingredients List. A summary flowchart of this algorithm can be found in Appendix 1.

Ingredients in the Ingredients List are listed by weight in descending over. Separate sets of

criteria were used depending on if a product contained non-concentrated FVNL or concentrated

FVNL.

Products containing only non-concentrated FVNL

To score at least 1 point, a FVNL must contribute greater than 40% to the total weight of the

product. A FVNL listed as the third ingredient in a product could account for, at most, one third

of the product’s weight (33%), assuming there are only three ingredients in the product and that

their weight is evenly distributed. Even in these unlikely circumstances, 33% falls below the

threshold of >40% required to score 1 point. Therefore, to score at least 1 point, a FVNL must be

one of the first two ingredients listed.

A product is allotted 2 points, and assumed to have a FVNL content of >60%, if a FVNL is listed

as the first ingredient, but there are other ingredients present that substantially contribute to the

product’s weight. A product receives 5 points and is assumed to have a FVNL content >80% if a

FVNL is listed as the first ingredient and other non-FVNL ingredients listed contribute only

minimal weight, such as preservatives, colour, vitamins, or minerals. A product receives 8

points, and is assumed to contain 100% FVNL, only if all of the ingredients in the product are

FVNL.

17

Products containing only concentrated FVNL

A FVNL must contribute ≥ 25% to the total weight for product to score 1 point. If a FVNL is

listed as the fourth ingredient in a product, the greatest possible weight it could account for is one

fourth of the total weight (25%), assuming the product contains only four ingredients and that the

weight of each ingredient is evenly distributed. Since such a circumstance is highly improbable,

it is assumed that a FVNL listed as the fourth ingredient will most likely contribute less than

25% to the total weight of the product. Therefore, to score at least one point, a FVNL must be

one of the first three ingredients listed.

A product is given 2 points, and assumed to contain ≥ 43% FVNL, if a FVNL is the first or

second ingredient but the non-FVNL ingredients in the product contribute substantially to the

weight. A product is allotted 5 points, and assumed to contain ≥ 67% FVNL, if a FVNL is the

first ingredient or if FVNL are the only ingredients in the product that substantially contribute to

the weight. A product receives 8 points and is assumed to contain 100% FVNL if it consists of

only FVNL ingredients. If a product contains a mix of concentrated and non-concentrated

FVNL, the criteria for non-concentrated FVNL is used.

2.4.3 The nutritional quality of nutritionally-enhanced foods

There is very little data examining the overall nutritional quality, including the saturated fat,

sugar, and sodium content, of foods with added nutrients. One study conducted in Ireland found

that nutrient profiles of voluntarily fortified foods were generally satisfactory, containing higher

levels of dietary fibre and lower levels of fat and saturated fat relative to energy content (24).

However, aside from this particular study, no other studies were found that directly assessed the

overall nutrient profiles of voluntarily fortified foods, supplemented foods, or functional foods.

Other studies have examined the association between fortified food consumption and the intake

of other nutrients. A study conducted in Ireland found that an increased consumption of fortified

foods in adults was associated with lower intakes of total fat and higher intakes of total

carbohydrates, total sugars and starch (58), and studies in France have found an association

between fortified breakfast cereals consumption and the replacement of energy from fats with

energy from carbohydrates in adults (59, 60) and children (60).

18

2.5 Concerns surrounding nutritionally-enhanced foods

Researchers have several concerns surrounding the expanding market of nutritionally-enhanced

foods. The growing popularity of foods with added nutrients has largely been attributed to an

increase in health-consciousness and the wish by consumers to purse a healthier lifestyle to

improve physical and psychological well-being (61, 62). However, there is speculation regarding

the benefits to health that the consumption of such foods are presumed to provide (63), and

concerns that the inappropriate use of nutritionally-enhanced foods may have negative effects on

population health.

Health professionals are wary that the consumption of foods with added vitamins and minerals,

especially in combination with supplement use, may result in high intakes of certain nutrients

that exceed tolerable upper intake levels and/or are not appropriate for certain age or gender

groups (5). The maximum levels of addition for micronutrients to fortified foods in Canada are

based on the highest Recommended Daily Allowances (RDAs)—or Adequate Intakes (AIs) if the

RDA is not available for a particular nutrient—and Tolerable Upper Levels (ULs) of individuals

within a population, in most cases the values indicated for males 19 years of age and older (64).

However, voluntarily fortified foods, such as breakfast cereals, are usually marketed towards all

members of a family, including children (23). This method represents a potential problem, as

setting maximum levels for the addition of vitamins and minerals to foods based on the age

group with the highest requirement level may result in unnecessarily high micronutrient intakes

in certain population subgroups, such as children (23).

In the case of supplemented foods, such as energy drinks and other nutrient-enhanced beverages,

a different approach has been used to set maximum levels of addition for micronutrients, since

these foods tend to contain much higher levels of added micronutrients that voluntarily-fortified

foods. Maximum levels were set based on data on the 95th percentile of daily dietary intake in the

general population, retrieved from the 2004 Canadian Community Health Survey Cycle 2.2, and

the estimated intake from supplements, determined from the highest levels of micronutrients

found in the five leading multivitamin and mineral supplements in Canada (65). Products that

contain micronutrients that are above the ULs for members of the general population, including

children, but below the UL for adults must carry a cautionary statement “For adults only.”

19

However, there is still concern that children and adolescents may be consuming these products,

since supplemented foods currently lack a product identifier and are easily accessible and sold on

the same shelves as other conventional foods in supermarkets. Health professionals have

suggested that there be no “adults only” category and that the levels of nutrients in all

supplemented foods should be safe for consumption for the general population (5). In addition,

certain nutrients, such as biotin and vitamin B12, do not have maximum levels of addition due to

a lack of defined ULs for these nutrients. Even though the literature has not yet produced

sufficient data to set ULs for these nutrients, this does not imply that there is no potential risk of

consuming these nutrients in any amount and caution should be exercised surrounding the levels

of these nutrients that manufacturers are adding to foods (65). There is also concern that many

functional foods contain herbal, bioactive, and novel ingredients, such as ginseng, that have a

limited history of safe use as a food, and that there is insufficient evidence to suggest that the

intake of such substances provide any real benefit to health (5, 63).

Another potential worry is that nutrients, such as vitamins, minerals and functional food

ingredients, will be added to foods that otherwise have poor nutritional value and will result in

higher intakes of nutrients, such as sodium and sugar, that may be detrimental to health (5).

Studies conducted in Europe have found that individuals with increased consumption of fortified

foods had lower intakes of total fats and higher intakes of carbohydrates—including higher

intakes of total sugars (58-60). The health effects of such an association remain unclear.

Although dietary guidelines have advised against too much fat in the diet (66) based on the view

that fats—particularly saturated fats—are a contributor to cardiovascular diseases (67), the

association between the two has recently become a controversial topic (67, 68). Furthermore, the

implications of replacing fats in the diet with carbohydrates remains uncertain. Researchers have

now suggested that substituting fats with certain types of carbohydrates, such as refined starches

and added sugars, provides no benefit to heart disease risk and may be detrimental to health (69,

70).

In addition, studies in Canada have investigated consumer response to the addition of nutrients to

foods. A Canada-wide survey conducted by the Dairy Farmers of Canada found that the majority

of adults and teens would increase their consumption of foods with poor nutritional value, such

20

as soft drinks, salty snacks, and fruit-flavoured drinks, if they were fortified, and that adults

would be more likely to feed their children these types of foods (71). In addition, focus groups

held across seven Canadian cities in 2004 revealed that consumers viewed the addition of

vitamins and minerals to foods of low nutritional value as an added bonus (72). The addition of

nutrients to otherwise ‘unhealthy’ foods is of even greater concern if heavy marketing on the

labels of such foods cause consumers to overlook levels of other nutrients, such as sugar and

sodium, and potentially lead to a shift in dietary patterns and displacement of healthy foods.

Studies have found that health claims have a positive effect on consumer attitudes (41-43, 46),

especially if they appear on certain products that are generally perceived as less ‘healthy’, such

as candies and spreads, as opposed to products that have already have a ‘healthy’ image, such as

yogurt and juices (47). Additionally, a conjoint study examining Danish, Finnish, and American

consumers’ perceptions of functional foods found that health claims appearing on functional

food labels had a positive effect on the perceived healthiness of these products, and that the

enrichment of ‘unhealthy’ foods, such as spreads, with bioactives, was perceived more positively

compared to the enrichment of ‘healthy’ foods, such as yogurt, with these substances (73). The

combined effects of adding vitamins, minerals, and substances to foods of low nutritional value

and heavy marketing on these products could have significant negative impacts on the dietary

patterns of Canadians.

2.6 Scope and objectives of thesis

The increasing popularity of foods with added nutrients have made researchers and health

professionals wary of the potential negative impacts of these foods on population health, such as

excessive nutrient intakes in certain population subgroups; the addition of micronutrients to

foods that otherwise have poor nutritional value; and excessive marketing of enhanced foods

causing consumers to overlook the levels of other nutrients, such as saturated fat and sugar (5).

However, the validity of these concerns cannot be judged at this time, as there is currently a lack

of data regarding nutritionally-enhanced foods in the Canadian marketplace. This thesis was

designed to conduct a comprehensive analysis on nutritionally-enhanced foods in Canada by

investigating the prevalence and nature of supplemented foods, functional foods, and foods with

high levels of voluntary fortification in the Canadian food market and the level of marketing on

such foods.

21

Study 1: The prevalence, nutritional quality, and marketing of supplemented foods

and functional foods in the Canadian marketplace

Objectives: This study aimed to: i) investigate the overall prevalence of supplemented foods

(SFs) and functional foods (FFs) using the University of Toronto Food Label Information

Program (FLIP) 2013 database; ii) identify the food categories containing the greatest

proportions of SFs and FFs; iii) determine the amount and types of added ingredients found in

SFs and FFs; iv) analyze the nutritional quality of SFs and FFs in the FLIP 2013 using the

validated Food Standards Australia New Zealand (FSANZ) nutrient profiling model (NPSC);

and v) quantify the occurrence of nutrition-related marketing, including nutrient content and

health claims, and FOP marketing, on the food labels of SFs and FFs. Hypothesis: It was

hypothesized that SFs and FFs would largely occur in food categories containing less healthy

products, such as cookies and high sugar beverages, and that the levels of added ingredients in

many products would be excessive and/or above Upper Levels (ULs). It was also hypothesized

that SFs and FFs in many food categories would be considered as ‘less healthy’ foods, and that

there would be high levels of marketing present on the food labels of SFs and FFs in these

categories compared to similar conventional foods.

Study 2: The nature and prevalence of voluntarily-fortified foods in the Canadian

marketplace

Objective: The objectives of this study were to: i) investigate the prevalence of voluntarily

fortified foods with high levels of added vitamins and minerals (VHVM) in the FLIP 2013; ii)

determine the nutritional quality of these foods using the validated FSANZ nutrient profiling

model; and iii) measure the level of marketing occurring on the packaging of these products.

Hypothesis: It was hypothesized that a large proportion of foods with high levels of voluntary

fortification would occur in food categories that are generally considered to be less healthy

foods, i.e. foods to be limited, according to Canada’s Food Guide guidance. It was also

hypothesized that many of these products would be considered ‘less healthy’ using the NPSC

model and contain high levels of food label marketing.

22

Chapter 3

3 - Study 1: The prevalence, nutritional quality, and marketing

characteristics of supplemented foods and functional foods in

the Canadian marketplace

Student’s contribution:

The original collection of food information in the FLIP 2013 database was previously conducted

by Alyssa Schermel (BSc. MSc.) and other members of the L’Abbé Lab before I began my MSc

thesis. However, I conducted all the research in this thesis related to SFs, FFs, and VHVMs using

the information provided in the FLIP 2013 database. In addition, I validated the marketing

information of foods in several food categories in the FLIP 2013 after the initial collection was

complete.

23

3.1 Abstract

Supplemented foods (SFs) and functional foods (FFs) (i.e. foods with high levels of vitamins,

minerals, bioactives, and other substances) have been entering the Canadian market and are a fast

growing sector of the food industry. Health professionals are wary that the consumption of these

foods may have negative implications on population health, such as leading to excessive nutrient

intakes that exceed Upper Levels (ULs) and/or are not appropriate for certain population

subgroups (5). The objective of the present study was to help fill gaps in knowledge surrounding

the prevalence and nature of SFs and FFs in the Canadian marketplace. Between May and

September 2013, information was collected from prepackaged foods carrying a Nutrition Facts

table (NFt) (n = 15,401) from 4 major grocery store chains across Canada: Loblaws, Metro,

Sobeys, and Safeway. Information from the NFt, Ingredients List, and marketing information—

such as health claims and front-of-pack (FOP) systems—was used to classify foods and

determine the type and/or amount of added ingredients present in each food. Less than 3% of

total foods collected in the FLIP 2013 were classified as SFs (n = 52) and FFs (326). The types

of foods most likely to be supplemented were certain types of beverages and fruit juices. FFs

were most commonly found in bakery products (e.g. grain-based bars), dairy products and

substitutes (e.g. yogurts), and cereals and other grain products (e.g. breakfast cereals). The most

frequently added supplemented ingredients were vitamin B6 (n = 20) and vitamin B12 (n = 15),

and the most common functional ingredients were inulin (n = 134) and probiotics (n = 85).

Although several SFs (n = 13) contained at least one vitamin/mineral that exceeded RDAs or

AIs, only 2 SFs contained a vitamin/mineral that exceeded the UL. This study provides baseline

data on SFs and FFs and can be used to design future studies investigating the consumption of

these foods by the Canadian population.

3.2 Introduction

Traditionally, the addition of nutrients to foods has been strictly regulated in Canada—permitted

only for purposes such as preventing or correcting nutrient deficiencies in the population,

restoring nutrients lost in the manufacturing process, addition to special purpose foods such as

infant formulas, and ensuring the nutritional equivalence of substitute foods (9). Recently,

however, foods with high levels of added nutrients, such as vitamins, minerals, amino acids,

24

bioactives and other substances, have gained market access and are a fast-growing sector of the

food industry (16, 26). Depending on the type and amount of nutrients added, these foods may be

referred to as supplemented foods (SFs) or functional foods (FFs).

Supplemented foods refer to nutritionally-enhanced foods containing high levels of added

vitamins, minerals, amino acids, or caffeine that do not comply with traditional fortification and

enrichment policies. To bypass the restrictive policies imposed under the food regulatory

framework, many SFs were previously classified as Natural Health Products (NHPs). However,

as the introduction of food-like NHPs began to flourish, Health Canada realized that many of

these products would be more appropriately classified under the Food and Drug Regulations

(FDR) as foods, as they were being packaged, marketed, and consumed as conventional foods

rather than drugs (16). Between 2010 and 2012, a process was undertaken to transition several

hundred products from the Natural Health Products Regulations (NHPR) to the food regulatory

framework, and rename them as supplemented foods (19). Despite their noncompliance with

food regulations, Health Canada permitted SFs that do not pose any immediate health risks to be

sold through the issuance of Temporary Marketing Authorization Letters (TMALs). Foods

carrying TMALs are temporarily granted market access for either 2-year or 5-year periods,

during which time manufacturers have to provide Health Canada with data to address

information gaps or reformulate their products to meet restrictions set by the FDR to continue

their sale (17). In addition to SFs, foods containing added ingredients that are associated with

providing a physiological benefit and/or reducing the risk of chronic disease—such as novel

fibres, protein isolates and concentrates, pro and prebiotics, and omega-3 and omega-6 fatty

acids—have been gaining popularity in the market. Health Canada refers to these foods as

‘functional foods’ (21). The term ‘functional food’ is used in a general sense, in that there is

currently no regulatory definition a food must follow or list of ingredients that a food must

contain to be deemed ‘functional’.

A series of guidance documents have been published by Health Canada (18-20, 38) to provide

food manufacturers with information on how supplemented and functional foods may be

formulated, including minimum and maximum levels for the addition of certain nutrients, such

as caffeine. However, to date, there is no separate regulatory framework or product identifier to

25

distinguish supplemented and functional foods from other conventional foods. As a result,

consumer confusion may arise surrounding the appropriate use of these foods within the context

of a healthy, balanced diet. Researchers and health professionals are concerned that the

consumption of nutritionally-enhanced foods may inadvertently have detrimental effects on

population health, such as resulting in high intakes of certain nutrients that exceed upper levels

(ULs) and/or are not suitable for certain age groups, and the overconsumption of substances,

such as herbals and bioactives, that have a limited history of safe use as a food (5). Additionally,

there are concerns that the addition of vitamins, minerals, and other nutrients to foods of

otherwise low nutritional value, such as sugary beverages and salty snacks, may negatively

impact the dietary patterns of Canadians and lead to the displacement of healthy foods (5, 71).

Despite these concerns, there has been no research examining SFs and FFs in Canada. Thus the

objective of this research was to evaluate the prevalence and nature of supplemented and

functional foods in the Canadian food supply. In Part I of this study, the frequency of SFs and

FFs, as well as the type and amount of ingredients added to these foods, was determined. In Part

II of this study, the nutritional quality and nutrition-related marketing of SFs and FFs was

analyzed.

.

3.3 Methodology

3.3.1 Data collection

Food Label Information Program (FLIP)

The University of Toronto Food Label Information Program (FLIP) 2013 is a database of food

package label information of foods sold in Canada. The FLIP 2013 contains nutrition

information on 15,401 prepackaged products collected between May and September 2013 from

the top four supermarket chains of Canada—Loblaws, Metro, Sobeys, and Safeway—and

represents 75.4% of the grocery retail marketshare (74). Complete information on the data

collection and processing of the FLIP 2013 can be found elsewhere (75).

Ten products were removed from the initial collection due to manufacturer labelling errors (e.g.

inconsistent validation by Atwater factors). Additionally, meal replacements, products intended

for children under the age of 4, and products lacking a standard Canadian NFt (e.g. Natural

26

Health Products) were also excluded from the present analysis, leaving a total of 15,332 product

in the final sample that was used for this study.

3.3.2 Data analysis

To distinguish nutritionally-enhanced foods, products containing any of the following types of

nutrients as an ingredient were included: vitamins, minerals, herbals, bioactives, protein

isolates/concentrates, amino acids, omega-3 fatty acids, omega-6 fatty acids, and novel food

ingredients. A complete list of these ingredients can be found in Appendix 2. Foods and

beverages that contained added nutrients due to fortification, enrichment, or food additive

purposes that are in compliance with the FDR were then excluded from these analyses.

Remaining products were categorized into two groups.

Supplemented foods

At the time that these analyses were conducted, Health Canada had not yet finalized its definition

of a supplemented food. Therefore, for the purpose of this study, SFs were defined as foods that

contain added vitamins, minerals, amino acids, or caffeine, as indicated in the Ingredients List,

added in amounts other than that which is permissible by the current FDR for fortification or

enrichment purposes.

Functional foods

Health Canada has defined a functional food as a food that “is similar in appearance to, or may

be, a conventional food, is consumed as part of a usual diet, and is demonstrated to have

physiological benefits and/or reduce the risk of chronic disease beyond basic nutritional

functions” (21). However, there is currently no strict list of ingredients that are deemed to be

considered ‘functional’. For the purpose of this study, foods that contained added nutrients other

than vitamins and minerals and made some indication, in the form of claims or other statements,

that they contained these added substances for the purpose of providing a health benefit were

categorized as functional foods. Foods that contained a functional ingredient but did not make

any claim or statement regarding its intended physiological benefit were excluded, since in such

cases, manufacturers may have added these substances to foods for other purposes (e.g. acacia

gum added as a food additive).

27

3.3.2.1. Part I: Characterizing the frequency of SFs and FFs, and the amount and type of

ingredients added

Foods in the FLIP 2013 were categorized into major and subcategories based on Schedule M of

the FDR (76). Since each major food category contains a wide range of food types, the frequency

of SFs and FFs was determined at the food subcategory level.

The amount of vitamin, mineral, or amino acid present in a SF was calculated using percent

Daily Values provided in the NFt (64) and analyzed per stated serving size. The resultant levels

were then compared to the highest Recommended Dietary Allowances (RDAs)—or Adequate

Intakes (AIs) if RDAs were not available—and Upper Limits (ULs) of children and adolescents

(4-13 years) and adults (19 years and older) within the population, excluding pregnant and

lactating women, and individuals over the age of 70 (77).

The amount of functional ingredient added to a food could not be determined from the

information provided in the NFt or Ingredients List and therefore was not calculated. However,

the type of functional ingredients added were characterized as: herbals/bioactives, novel fibres,

omega-3/omega-6 fatty acids, protein concentrates/isolates, and other novel ingredients.

3.3.2.2. Part II: Determining the nutritional quality and level of marketing of SFs and FFs

The Nutrient Profiling Scoring Criterion (NPSC) created by Food Standards Australia New

Zealand (FSANZ) (54) was used to determine the nutritional quality of foods in the FLIP 2013.

The NPSC is a validated nutrient profiling model that uses a points-based system to determine

the healthiness of a food (57). Foods are first classified into one of three categories. Category 1

foods consist of beverages; Category 3 foods consist of cheese, edible oil spreads, butter, and

margarine; and Category 2 foods consist of remaining foods that are not included in either of the

other categories. Each food obtains a score based on category-specific nutrient thresholds. Points

are added for energy content and nutrients that that have been associated with an increased risk

of chronic disease—saturated fat, total sugars, and sodium—and points are deducted for nutrients

that are thought to be beneficial to health—fibre, protein, and fruit/vegetable/nut/legume content.

In this system, the lower the score, the ‘healthier’ the food. Scores range from -18 to 81.

Category 1, 2, and 3 foods are permitted to carry health claims in Australia and New Zealand

only if they receive final scores less than 1, 4, or 28, respectively. Foods scoring less than these

28

cut points were rated ‘healthy’ and foods scoring above these cut points were rated ‘less healthy’.

Further details of the FSANZ nutrient-profiling methodology (NPSC) can be found in Appendix

4.

NPSC scores were calculated for all foods in the FLIP 2013 database and medians were

compared between SFs and non-SFs and between FFs and non-FFs within each food

subcategory. Median final scores were also examined to determine if these nutritionally-

enhanced foods would be considered ‘healthy’ enough to be permitted to carry health claims

under the FSANZ NPSC system. In the case of FFs, it was anticipated that certain added

ingredients (i.e. novel fibres and protein isolates/concentrates) may have contributed to final

NPSC scores, as points are allotted based on the fibre and protein content of foods. Therefore, to

determine the extent to which functional ingredients in FFs altered final NPSC scores, points

received or deducted for each nutrient contributing to the final score were determined in food

subcategories containing large proportions (>20%) of FFs containing added novel fibres or added

protein isolates/concentrates.

Nutrition-related marketing present on the food labels of products in the FLIP 2013 were

classified as nutrient content claims, health claims, and various front-of-pack (FOP)

systems/symbols, according to the Canadian FDR (as described previously). In the present study,

each individual claim or FOP system/symbol was calculated as one marketing item. Repeats of

the same marketing item on different panels of a food package were not included as separate

marketing items. Marketing items were categorized as either government regulated claims (i.e.

nutrient content and health claims) or claims that lack specific regulations (i.e. FOP

symbols/systems (FOPS)). The amount of regulated claims, FOPS, and total marketing was

compared between SFs and non-SFs, and between FFs and non-FFs. Statements that appeared on

a product but were not related to nutrition (e.g. statements regarding taste) were not included as

claims.

3.3.2.3 Statistical Analyses

Statistical analyses were conducted using SAS version 9.3 (Statistical Analysis Software Co,

Cary NC). Categorical data were presented as frequencies and percentages. Continuous data

were presented as medians, Q1s, and Q3s. Only food subcategories containing at least 10 SFs or

10 FFs were included in nutritional quality and marketing analyses. The Wilcoxon signed rank

29

test was used to make comparisons in FSANZ NPSC scores and marketing items between SFs

and non SFs, and between FFs and non-FFs within each food subcategory. Chi squared tests

were used to make comparisons between groups in the proportion of products meeting ‘healthy’

cutpoints to be eligible to carry a health claim based on the FSANZ NPSC system. A P value of

<0.05 was considered significant.

3.4 Results

3.4.1 Part I: Characterizing the frequency of SFs and FFs, and the amount and type of

ingredients added

Supplemented Foods

A total of 52 foods and beverages (<1% total products) were classified as SFs (Appendix 3). The

most commonly added supplemented ingredients were vitamin B6 (n = 20), vitamin B12 (n =

15), and niacin/vitamin B1 (n = 13). Overall, 13 SFs contained at least one vitamin/mineral that

exceeded the Recommended Dietary Allowance (RDA) or AI (Adequate Intake).

The subcategories containing the greatest numbers of supplemented foods (Table 1) were

carbonated and non-carbonated beverages and wine coolers (n = 15, 6% of total foods in

subcategory), and juices, nectars, and fruit drink substitutes (n = 24, 4% of total foods in

subcategory). The only micronutrients added to SFs occurring in the juices, nectars, and fruit

drink substitutes subcategory were vitamins and/or minerals, with a median of 2 added per SF.

The most commonly added vitamins and minerals in this subcategory were calcium (n = 10),

vitamin D (n = 9), thiamine/vitamin B1 (n = 9), and folic acid (n = 7). None of the SFs in the

juices, nectars, and fruit drink substitutes subcategory contained added nutrients in amounts that

exceeded the RDA/AI or UL (Table 2).

In the carbonated, non-carbonated beverages and wine coolers subcategory—including energy

drinks—SFs contained a median of 5 added micronutrients, including vitamins and minerals,

amino acids and caffeine. The most commonly added vitamins and/or minerals in this

subcategory were vitamin B6 (n=14), vitamin B12 (n=11), niacin/vitamin B3 (n=11), and

pantothenic acid/vitamin B5 (n=11). The most commonly added vitamins also tended to be the

ones added in the highest amounts (Table 2). SFs in this category contained vitamin B6 (up to

7.0 mg), vitamin B12 (up to 12 µg), niacin/vitamin B1 (up to 39.1 mg), and pantothenic

30

acid/vitamin B5 (up to 20.3 mg) in amounts that exceeded the RDAs/AIs of both children and

adults; and 2 SFs contained niacin/vitamin B1 in an amount (39.1 mg) exceeding the ULs of both

children and adults. In addition to vitamins and minerals, a large proportion of supplemented

foods in this subcategory contained caffeine (61%) and the amino acid taurine (61%), and a

smaller proportion contained the amino acid L-theanine (11%) (Table 3). Although very high

levels of these nutrients were added, no SFs contained caffeine or amino acids in amounts

exceeding the maximum levels permitted for addition as set in the Guidance Documents for

Temporary Marketing Authorizations (TMAs)(18).

Functional foods

A total of 326 (2% of total foods) foods and beverages were classified as functional foods (Table

4). Major food categories containing the greatest numbers of functional foods were dairy

products and substitutes (n=102), bakery products (n=98), and cereals and other grain products

(n=76). Food subcategories containing the greatest proportions of foods that are functional

include shakes and shake substitutes (36%), grain-based bars, with filling or coating (31%),

yogurt (32%), ready-to-eat breakfast cereals, puffed and coated, without fruit or nuts (25%),

ready-to-eat breakfast cereals, fruit and nut type, granola, biscuit type cereals (18%), and grain-

based bars, without filling or coating (17%). Many of the same subcategories also contained the

greatest number of functional food products including: yogurt (n=74), grain-based bars, with

filling or coating (n=33), and ready-to-eat breakfast cereals, fruit and nut type, granola, biscuit

type cereals (n=30). The most commonly added types of functional ingredients were novel fibres

(n=191) and herbals/bioactives (n=109), with inulin (n=134) and probiotic bacterial cultures

(n=85) being the most commonly added ingredient in each category, respectively. A complete

list of functional ingredients added to foods in each major food category can be found in Table

5.

3.4.2 Part II: Determining the nutritional quality and level of marketing of SFs and FFs

Nutritional value of supplemented foods and functional foods

The median nutrient profiling scores of SFs in both food subcategories analyzed were within the

threshold (<1) to carry health claims using the FSANZ NPSC system, and in both food

31

subcategories, SFs did not have median NPSC scores that were higher (i.e. less healthy) than

non-SFs (Table 6). In the carbonated and non-carbonated beverages subcategory, there was no

statistical difference in median NPSC scores of SFs and non-SFs. Additionally, there was no

difference between SFs and non-SFs in this subcategory when comparing the proportions of

products that met cutpoints to be considered ‘healthy’ (Table 7). SFs in the juices, nectars, and

fruit drink substitutes subcategory, on the other hand, had significantly lower (i.e. more healthy)

NPSC scores and a greater proportion of products that met ‘healthy’ cutpoints compared to non-

SFs in the same subcategory.

The median NPSC scores of FFs in four out of ten subcategories analyzed were overall

‘healthier’ (i.e. lower) compared to non-FFs in these categories (Table 8). These subcategories

include: cookies and graham wafers, grain-based bars (with filling or coating), grain-based bars

(without filling or coating), and pastas without sauce. In order to understand the source of these

differences in NPSC scores, the final scores of products in these subcategories were broken

down into the NPSC score components (Table 10). The median points deducted for fibre content

in FFs were significantly greater than non-FFs in all four subcategories, suggesting that added

novel fibres in FFs somewhat contributed to the difference in final scores seen between FFs and

non-FFs. However, FFs in the cookies and graham wafers, grain-based bars (with filling or

coating), and grain-based bars (without filling or coating) subcategories also had significantly

lower points added for other nutritional components, such as energy and total sugars, compared

to non-FFs, suggesting that high fibre content was not the sole reason FFs in these subcategories

had overall healthier final scores compared to non-FFs. Despite FFs being overall ‘healthier’

than non-FFs in these three subcategories, the median NPSC scores of FFs were still too high

(i.e. not healthy enough) to be permitted to carry health claims using the FSANZ NPSC system

(Table 8). Additionally, there was no difference between FFs and non-FFs within two of these

subcategories—cookies and graham wafers, and grain-based bars (with filling or coating)—in

the proportion of products meeting ‘healthy’ cutpoints (Table 9).

There were no statistical differences in median NPSC scores between FFs and non-FFs in the

remaining food subcategories examined. These subcategories included: carbonated and non-

carbonated beverages and wine coolers; ready-to-eat breakfast cereals (puffed and coated,

without fruit or nuts, very high fibre); ready-to-eat breakfast cereals (fruit and nut type, granola,

32

biscuit type); plant-based beverages, milk, buttermilk, and milk-based drinks; yogurt; and juices,

nectars, and fruit drink substitutes. The distribution of points deducted or received per nutrient

varied according to food subcategory (Table 10). FFs in all but one of these subcategories—

ready-to-eat breakfast cereals (puffed and coated, without fruit or nuts, very high fibre)—were

deemed sufficiently ‘healthy’ to carry health claims.

The median NPSC scores of FFs were not significantly higher (i.e. less healthy) than non-FFs in

any of the subcategories analyzed.

Marketing on food labels of supplemented foods and functional foods

Regardless of the overall nutritional quality of the food, both SFs and FFs were more heavily

marketed than comparable foods that do not contain supplemental or functional ingredients

(Tables 11 and 12). The median number of total marketing items present on food labels was

statistically higher in SFs in comparison to non-SFs in both food subcategories examined. SFs in

both subcategories had a greater number of regulated claims (i.e. nutrient content and health

claims) than non-SFs. However, FOP marketing was greater on SFs in comparison to non-SFs

only in the juices, nectars, and fruit drink substitutes subcategory. There was no statistical

difference in FOPS between SFs and non-SFs in the carbonated and non-carbonated beverages

and wine coolers subcategory.

In all subcategories analyzed, FFs had significantly higher levels of nutrition marketing on food

labels than non-FFs (Table 12). In five subcategories, FFs had significantly higher levels of both

regulated claims and FOPS in comparison to non-FFs within each category. In two

subcategories—grain-based bars (without filling or coating); and ready-to-eat breakfast cereals

(fruit and nut type, granola, biscuit type)—there was no statistical difference in the number of

regulated claims between FFs and non-FFs. However, in these subcategories, FFs had

significantly greater numbers of FOPS than non-FFs. In two other subcategories—carbonated

and non-carbonated beverages and wine coolers; and yogurt—the opposite trend occurred, where

there was a significantly higher number of regulated claims appearing on the food labels of FFs

in comparison to non-FFs, but no statistical difference in the amount of FOP marketing between

these types of foods. In one subcategory (plant-based beverages, milk, buttermilk, and milk-

based drinks), there was no statistical difference in the level of marketing between FFs and non-

FFs when regulated claims and FOPS were examined separately.

33

Table 1. Prevalence of supplemented foods* (SFs) in the Canadian marketplace in 2013

Food category and subcategory Total

N

Supplemented foods

n (% of total foods)

Beverages

Carbonated and non-carbonated beverages

and wine coolers

268

15 (6)

Sports drinks and water

125 3 (2)

Coffee 29 1 (3)

Cereals and other grain products

Ready-to-eat breakfast cereals, puffed and

coated, without fruit or nuts, very high

fibre

77

1 (1)

Dairy products and substitutes

Cheese, including cream cheese and

cheese spread

453

2 (<1)

Plant-based beverages, milk, buttermilk

and milk-based drinks, such as chocolate

milk

247

2 (1)

Fruit and fruit juices

Juices, nectars and fruit drink substitutes

636

24 (4)

Vegetables

Vegetable juice and vegetable drink

43

4 (9)

* Supplemented foods were defined as foods that contain added vitamins, minerals, amino acids, or caffeine added in amounts

other than that which is permissible by the current FDR for fortification or enrichment purposes.

34

Table 2. Levels of added vitamins and minerals in the most common supplemented food*(SF) categories

Food

category¥

Micronutrient Number of SFs

containing nutrient

n (% of total

SFs/category)

RDA or AI

/UL

Median amount/

serving

Amount/serving (%DV)

Adult Child Min Max

Juices, nectars

and fruit drink

substitutes

Folic acid (µg)

7 (29)

400/1000

300/600

99

66 (30)

132 (60)

Riboflavin (mg) 2 (8) 1.3/ND 0.9/ND 0.1 0.1 (6) 0.1 (6)

Thiamine (mg) 9 (38) 1.2/ND 0.9/ND 0.2 0.1 (8) 0.2 (15)

Vitamin B6 (mg) 2 (8) 1.3/100 1.0/60 0.12 0.12 (6) 0.12 (6)

Vitamin D (IU) 9 (38) 600/4000 600/4000 100 16 (8) 120 (60)

Vitamin E (mg) 5 (21) 15/1000 11/600 2 2 (20) 2.5 (25)

Calcium (mg) 10 (42) 1000/2500 1300/3000 330 88 (8) 330 (30)

Iron (mg) 6 (25) 8/45 8/40 1.4 1.4 (10) 2.1 (15)

Magnesium (mg) 2 (8) 400/350 240/350 25 25 (10) 25 (10)

Potassium (mg) 4 (17) 4700/ND 4500/ND 297.5 245 (7) 385 (11)

Carbonated

and non-

carbonated

beverages and

wine coolers

Niacin (mg) 11 (61) 16/35 12/20 20.7 5.8 (25) 39.1 (170)

Pantothenic acid

(mg)

11 (61) 5/ND 4/ND 4.9 1.8 (25) 20.3 (290)

Vitamin B6 (mg) 15 (83) 1.3/100 1/60 4.0 0.5 (25) 7.0 (390)

Vitamin B12 (µg) 12 (67) 2.4/ND 1.8/ND 8.1 5 (250) 12 (600)

Vitamin C (mg) 2 (11) 90/2000 45/1200 78 100 (100) 160 (160)

Calcium (mg) 1 (6) 1000/2500 1300/3000 330 330 (30) 330 (30)

Zinc (mg) 4 (22) 11/40 8/23 0.9 0.9 (10) 3.6 (40)

* Supplemented foods were defined as foods that contain added vitamins, minerals, amino acids, or caffeine added in amounts other than that

which is permissible by the current FDR for fortification or enrichment purposes. ¥ Food subcategories containing at least 10 supplemented foods

35

are shown. RDAs, AIs, and ULs are based on the highest requirements in adults (excluding pregnant and lactating women, and individuals over

the age of 70) and children aged 4-13 (77). Adequate Intakes (AIs) are followed by Abbreviations – SF = supplemented food; RDA =

Recommended Dietary Allowance; AI = Adequate Intake; UL = Upper Limit; % DV = Percent Daily Value.

36

Table 3. Added caffeine and amino acids in supplemented foods* (SFs) in Canada in 2013

Food

category

Micronutrient Number of SFs

containing nutrient

n (% of total SFs)

Max. amount

permitted¥

Amount/serving

Median Min Max

Carbonated

and non-

carbonated

beverages

and wine

coolers

Taurine

(mg/serving)

11 (61) 3000 1000 200 2000

L-theanine

(mg/serving)

2 (11) 300 25 25 25

Caffeine

(ppm)

11 (61) 400 320 320 360

* Supplemented foods were defined as foods that contain added vitamins, minerals, amino acids, or

caffeine added in amounts other than that which is permissible by the current FDR for fortification or

enrichment purposes. ¥ Maximum levels of addition for caffeine and amino acids are set out in Guidance

Documents pertaining to products that have been issued TMAs (17, 18). Abbreviations – SF =

supplemented food.

37

Table 4. Prevalence of functional foods* (FFs) in the Canadian marketplace in 2013 by food

subcategory

Food category and subcategory

(n) total

products

Number of

FFs/category

(%)

Bakery products

Grain-based bars, with filling or coating

106 33 (31)

Grain-based bars, without filling or coating

100 17 (17)

Cookies and graham wafers 391 22 (6)

Bagels, tea biscuits, scones, rolls, buns, croissants, tortillas, soft bread

sticks, soft pretzels and corn bread

288 6 (2)

Crackers, hard bread sticks and melba toast

279 5 (2)

Bread, excluding sweet quick-type rolls 231 5 (2)

French toast, pancakes and waffles 59 4 (7)

Coffee cakes, doughnuts, danishes, sweet rolls, sweet quick-type

breads and muffins

123 4 (3)

Brownies 28 2 (7)

Beverages

Carbonated and non-carbonated beverages and wine coolers

268 14 (5)

Sports drinks and water

125 2 (2)

Coffee

29 1 (3)

Cereals and other grain products

Ready-to-eat breakfast cereals, fruit and nut type, granola, biscuit type

cereals

170 30 (18)

Pastas without sauce 439 23 (5)

Ready-to-eat breakfast cereals, puffed and coated, without fruit or nuts,

very high fibre

77 19 (25)

Hot breakfast cereals

107 4 (4)

38

Table 4. (continued)

Food category and subcategory

(n) total

products

Number of

FFs/category

(%)

Dairy products and substitutes

Yogurt 233 74 (32)

Plant-based beverages, milk, buttermilk and milk-based drinks 247 14 (6)

Quark, fresh cheese and fresh dairy desserts 99 6 (6)

Shakes and shake substitutes 11 4 (36)

Cheese, including cream cheese and cheese spread 453 4 (1)

Fruit and fruit juices

Juices, nectars and fruit drink substitutes 637 14 (2)

Vegetables

Vegetable juice and drink 43 2 (5)

Meat, poultry, their products and substitutes

Luncheon meats 101 1 (1)

Nuts and seeds

Peanut butter

50 1 (2)

Desserts

Dairy desserts, frozen (cakes, bars, sandwiches or cones) 187 2 (1)

Ice cream, ice milk, frozen yogurt and sherbet 395 1 (<1)

Fats and oils

Butter, margarine, shortening and lard 91 5 (6)

Dressings for salad 252 3 (1)

Marine and freshwater animals

Marine and fresh water animals without sauce 209 4 (2)

*Functional foods were defined as foods that contained substances (other than vitamins and minerals) added for the purpose of

providing a health benefit.

39

Table 5. Ingredients added to functional foods in the Canadian food market in 2013

*Functional foods were defined as foods that contained substances (other than vitamins and minerals) added for the purpose of

providing a health benefit. ¥ Major food categories containing at least 10 functional foods (FFs) are shown. ǂ Entries in

bold type represent categories of functional ingredients. Abbreviations – FF = functional food.

Number of FFs¥ containing ingredient per food category

N (% of total FFs in food category)

Ingredient Bakery

products

(n = 98)

Beverages

(n = 17)

Cereals and

other grains

(n = 76)

Dairy products

and substitutes

(n = 102)

Fruit and fruit

juices

(n = 14)

Novel fibres

Inulin 78 (80) 2 (12) 36 (47) 11 (11) 4 (29)

Corn bran 7 (7) - 14 (18) - -

Wheat bran 38 (39) - 25 (33) 1 (1) -

Oat bran 9 (9) - 2 (3) - -

Oat hull fibre - - 6 (8) - -

Beta-glucan 1 (1) - - - -

Acacia gum - - 1 (1) - 4 (29)

Polydextrose - - 1 (1) - -

Dextrin - - 1 (1) - 1 (7)

Psyllium seed husk - - 2 (3) - -

TOTAL: 92 (94) 2 (12) 74 (97) 11 (11) 8 (57)

Herbals/bioactives

Probiotic cultures 3 (3) - 2 (3) 79 (78) 1 (7)

Ginseng extract - 7 (41) - - -

Yerba mate extract - 1 (6) - - -

Milk thistle seed extract - 2 (12) - - -

Green tea extract 3 (3) 2 (24) 1 (1) - -

Guarana seed extract - 6 (35) - - -

Green coffee bean extract - 3 (18) - - -

Bee pollen - - 1 (1) - -

Maca root - - 1 (1) - -

Red wine extract 1 (1) - - - -

Rosemary extract - 1 (1) - -

TOTAL: 7 (7) 16 (94) 6 (8) 79 (78) 1 (7)

Omega-3/omega-6

DHA oil - - - 1 (1) -

Encapsulated fish oil - - - 4 (4) 2 (14)

Flaxseed oil - - - 11 (11) 1 (7)

TOTAL: - - - 15 (15) 3 (21)

Protein

concentrates/isolates

Soy protein 7 (7) - 6 (8) 1 (1) -

Whey protein 4 (4) 1 (6) - 4 (4) -

TOTAL: 11 (11) 1 (6) 6 (8) 4 (4) -

Other novel ingredients - - - - 3 (21)

Plant sterols - - - - 3 (21)

40

Table 6. Comparison of NPSC nutrient profile scores* of supplemented foods¥ (SFs) and non-

supplemented foods (non-SFs) in the Canadian marketplace in 2013

Food category

SFs (n)

Non-SFs

(n)

Median nutrient

profiling score

(Q1, Q3)ǂ

p-

value

Direction of

significanceѱ

SF Non-SF

Carbonated and

non-carbonated

beverages and

wine coolers

15

253

0 (-2, 2)

1 (0, 2)

0.52

NS

Juices, nectars

and fruit drink

substitutes

24

612

-2 (-3, 0)

0 (-2, 1)

0.02

Positive

* Nutrient profile scores are based on the FSANZ Nutrient Profiling Soring Criterion (NPSC). ¥ Supplemented

foods (SFs) were defined as foods containing added vitamins, minerals, amino acids, or caffeine added in

amounts beyond what is permissible for fortification/enrichment purposes according to the FDR. Food

subcategories containing at least 10 SFs were analyzed. ǂ Q1 and Q3 refer to 25% and 75% quartile median

values. ѱ A p-value < 0.05 was considered significant. Positive significance indicates that median scores of

SFs are significantly lower (or “healthier”) than median scores of non-SFs. NS indicates no significance.

Products meeting specific cut points (beverages: <1; cheese, edible oil, edible oil spreads, margarine, or butter:

<28; all other foods: <4) based on the NPSC system are considered ‘healthy’ and would be permitted to carry a

health claim in Australia/New Zealand.

41

Table 7. Number and proportion of SFs* and non-SFs meeting ‘healthy’ cutpoints based on the FSANZ NPSC system¥

* Supplemented foods (SFs) were defined as foods containing added vitamins, minerals, amino acids, or caffeine added in amounts beyond what is

permissible for fortification/enrichment purposes according to the FDR. Food subcategories containing at least 10 SFs were analyzed. ¥ Products meeting

specific cut points (beverages: <1; all other foods except for cheese, edible oil, edible oil spreads, margarine, or butter: <4) based on the FSANZ NPSC

system are considered ‘healthy’ and would be permitted to carry a health claim in Australia/New Zealand. ǂ p < 0.05 was considered significant.

Food subcategory

SFs (n)

Non-SFs (n)

Number of foods meeting ‘healthy’

cutpoints (%)

p-valueǂ

SFs

Non-SFs

Carbonated and non-carbonated

beverages and wine coolers

15

253

8 (53)

104 (41)

0.35

Juices, nectars and fruit drink

substitutes 24 612 20 (83) 379 (62) 0.03

42

Table 8. NPSC nutrient profile scores* of functional foods¥ (FFs) and non-functional foods (non-FFs) in the Canadian marketplace in 2013

Food subcategory

FFs (n)

Non-FFs (n)

Nutrient profiling score

Mdn (Q1, Q3)ǂ

p-value

Direction of

significanceѱ

FF Non-FF

Cookies and graham wafers

22

369

11 (9, 13)

20 (15, 23)

< 0.0001

Positive

Grain-based bars (with filling or

coating)

33

73

11 (9, 12)

16 (10, 19)

0.0002

Positive

Grain-based bars (without filling or

coating)

17

83

4 (2, 9)

9 (8, 11)

0.002

Positive

Carbonated and non-carbonated

beverages and wine coolers

14

254

0 (0, 2)

1 (0, 2)

0.24

NS

RTE breakfast cereals (puffed, coated,

w/o fruit or nut, very high fibre)

19

58

10 (8, 13)

12 (3, 14)

0.28

NS

RTE breakfast cereals (fruit and nut

type, granola, biscuit type)

30

140

2 (1, 10)

1 (-1, 8)

0.09

NS

Pastas without sauce

23

416

-6 (-6, -6)

-4 (-4, -3)

< 0.0001

Positive

Plant-based beverages, milk,

buttermilk and milk-based drinks

14

233

0 (-1, 2)

-1 (-1, 0)

0.1

NS

Yogurt

74

159

0 (-2, 2)

-1 (-2, 1)

0.09

NS

Juices, nectars, and fruit drink

substitutes

14

622

0 (0, 0)

0 (-3, 1)

0.67

NS

43

* Nutrient profile scores are based on the FSANZ Nutrient Profiling Soring Criterion (NPSC). ¥ Functional foods (FFs) were defined as foods containing

added ingredients other than vitamins and minerals for the purpose of providing a health benefit. Food subcategories containing at least 10 FFs were

analyzed. ǂ Q1 and Q3 refer to 25% and 75% quartile median values. ѱ A p-value < 0.05 was considered significant. Positive significance indicates that

median scores of FFs are significantly lower (or “healthier”) than median scores of non-FFs. NS indicates no significance in nutrient profiling scores.

Products meeting specific cut points (beverages: <1; cheese, edible oil, edible oil spreads, margarine, or butter: <28; all other foods: <4) based on the

NPSC system are considered ‘healthy’ and would be permitted to carry a health claim in Australia/New Zealand.

44

Table 9. Number and proportion of FFs* and non-FFs meeting ‘healthy’ cutpoints based on the FSANZ NPSC system¥

* Functional foods (FFs) were defined as foods containing added ingredients other than vitamins and minerals for the purpose of providing a health benefit. Food

subcategories containing at least 10 FFs were analyzed. ¥ Products meeting specific cut points (beverages: <1; all other foods except for cheese, edible oil, edible

oil spreads, margarine, or butter: <4) based on the FSANZ NPSC system are considered ‘healthy’ and would be permitted to carry a health claim in

Australia/New Zealand. ǂ p < 0.05 was considered significant.

Food subcategory

FFs (n)

Non-FFs (n)

Number of foods meeting ‘healthy’

cutpoints (%)

p-valueǂ

FFs

Non-FFs

Cookies and graham wafers

22

369 0 (0) 3 (1) 0.67

Grain-based bars (with filling or coating)

33

73 0 (0) 2 (3) 0.34

Grain-based bars (without filling or coating)

17

83 8 (47) 5 (6) <.0001

Carbonated and non-carbonated beverages and wine

coolers

14

254 8 (57) 104 (41) 0.23

RTE breakfast cereals (puffed, coated, w/o fruit or nut,

very high fibre)

19

58 4 (21) 15 (26) 0.67

RTE breakfast cereals (fruit and nut type, granola, biscuit

type)

30

140 18 (60) 92 (66) 0.55

Pastas without sauce

23

416 23 (100) 413 (99) 0.68

Plant-based beverages, milk, buttermilk and milk-based

drinks

14

233 9 (64) 175 (75) 0.37

Yogurt

74

159 70 (95) 150 (94) 0.94

Juices, nectars and fruit drink substitutes

14

622 13 (93) 388 (62) 0.02

45

Table 10. Breakdown of NPSC scores¥ of functional foods (FFs)

ǂ compared to non-functional foods (non-FFs) per food subcategory

Food subcategory*

FFs

(n)

Non-FFs

(n)

Nutrient

Median points scored (Q1, Q3)

p-value

Direction of

significance

FFs

Non-FFs

Cookies and graham

wafers

22

369

Energy

5 (4, 5)

5 (5, 6)

0.003

Positive

Saturated fat

3 (3, 4)

8 (4, 10)

< .0001

Positive

Total sugars

6 (5, 7)

7 (5, 8)

0.002

Positive

Total sodium

2.5 (1, 3)

3 (2, 4)

0.27

NS

FVNL

0 (0, 0)

0 (0, 0)

< .0001

Positive

Protein

0 (0, 0)

0 (0, 0)

0.34

NS

Fibre

5 (5, 5)

3 (0, 3)

< .0001

Positive

Grain-based bars (with

filling or coating)

33

73

Energy

4 (4, 5)

5 (4, 5)

0.001

Positive

Saturated fat

3 (1, 4)

5 (1, 7)

0.003

Positive

Total sugars

7 (5, 7)

7 (6, 8)

0.003

Positive

Total sodium

2 (2, 3)

2 (1, 3)

0.98

NS

FVNL

0 (0, 0)

0 (0, 0)

0.20

NS

Protein

0 (0, 0)

0 (0, 0)

0.09

NS

Fibre

5 (5, 5)

3 (3, 5)

< .0001

Positive

46

Table 10. (continued)

Food subcategory

FFs

(n)

Non-FFs

(n)

Nutrient

Median points scored (Q1, Q3)

p-value

Direction of

difference

FFs

Non-FFs

Grain-based bars

(without filling or

coating)

17

83

Energy

4 (4, 5)

5 (4, 5)

0.008

Positive

Saturated fat

1 (1, 3)

1 (1, 3)

0.83

NS

Total sugars

4 (4, 5)

6 (5, 7)

0.001

Positive

Total sodium

3 (2, 3)

2 (2, 3)

0.02

Negative

FVNL

0 (0, 0)

0 (0, 0)

0.88

NS

Protein

3 (0, 5)

0 (0, 0)

< .0001

Positive

Fibre

5 (5, 5)

5 (4, 5)

0.003

Positive

RTE breakfast cereals

(puffed, coated, w/o

fruit or nut, very high

fibre)

19

58

Energy

4 (4, 5)

4 (4, 4)

0.02

Negative

Saturated fat

0 (0, 0)

0 (0, 0)

0.26

NS

Total sugars

6 (4, 7)

4 (2, 7)

0.39

NS

Total sodium

5 (4, 6)

5 (4, 7)

0.59

NS

FVNL

0 (0, 0)

0 (0, 0)

0.33

NS

Protein

0 (0, 0)

0 (0, 4)

0.54

NS

Fibre

5 (5, 5)

3 (3, 5)

< .0001

Positive

47

Table 10. (continued)

Food subcategory

FF

(n)

Non-FF

(n)

Nutrient

Median points scored (Q1, Q3)

p-value

Direction of

significance

FFs

Non-FFs

RTE breakfast cereals

(fruit and nut type,

granola, biscuit type)

30

140

Energy

4 (4, 5)

4 (4, 5)

0.02

Positive

Saturated fat

0 (0, 0)

0 (0, 2)

0.01

Positive

Total sugars

4.5 (3, 5)

4 (3, 5)

0.28

NS

Total sodium

2 (2, 5)

1 (0, 2)

< .0001

Negative

FVNL

0 (0, 0)

0 (0, 0)

0.78

NS

Protein

3.5 (0, 5)

5 (0, 5)

0.21

NS

Fibre

5 (5, 5)

5 (5, 5)

0.55

NS

Pastas without sauce

23

416

Energy

4 (4, 4)

4 (4, 4)

0.68

NS

Saturated fat

0 (0, 0)

0 (0, 0)

0.26

NS

Total sugars

0 (0, 0)

0 (0, 0)

0.37

NS

Total sodium

0 (0, 0)

0 (0, 0)

0.24

NS

FVNL

0 (0, 0)

0 (0, 0)

0.28

NS

Protein

5 (5, 5)

5 (5, 5)

0.06

NS

Fibre

5 (5, 5)

3 (3, 3)

< .0001

Positive

48

Table 10. (continued)

Food subcategory

FF

(n)

Non-FF

(n)

Nutrient

Median points scored (Q1, Q3)

p-value

Direction of

significance

FFs

Non-FFs

Yogurt

74

159

Energy

1 (0, 1)

1 (0, 1)

0.91

NS

Saturated fat

1 (0, 1)

0 (0, 1)

0.003

Negative

Total sugars

2 (2, 2)

2 (0, 2)

0.04

Negative

Total sodium

0 (0, 0)

0 (0, 0)

1.00

NS

FVNL

0 (0, 0)

0 (0, 0)

0.09

NS

Protein

2 (2, 3)

2 (2, 4)

0.36

NS

Fibre

0 (0, 0)

0 (0, 0)

0.04

Positive

* As large proportions of FFs contained added novel fibres, a subanalysis was conducted to examine the contribution of these added

ingredients in determining the final NPSC scores of FFs. Food subcategories containing beverages were not analyzed, as beverages are

not permitted to score fibre points according to the NPSC.

49

Table 11. Level of nutrition marketing on food labels of supplemented foods* (SFs) and non-supplemented foods (non-SFs) in

Canada in 2013

* Supplemented foods (SFs) were defined as foods containing added vitamins, minerals, amino acids, or caffeine added in amounts beyond what is

permissible for fortification/enrichment purposes according to the FDR. Food subcategories containing at least 10 SFs were analyzed. ¥ Total marketing

items include the total number of regulated claims (i.e. nutrient content claims and health claims) and Front-of-Pack systems (FOPS). ѱ Mdn represents

median values. Q1 and Q3 represent 25% and 75% quartile median values. ǂ p < 0.05 is considered significant. Positive significance denotes that SFs had

a significantly greater number of total marketing/regulated claims/FOPS than non-SFs. NS represents no significance.

Food

subcategory

SFs

Non- SFs

Total marketing

items¥

Mdn (Q1, Q3)ѱ

Significance

(p)ǂ

Regulated claims

Mdn (Q1, Q3)

Significance

(p)

FOPS

Mdn (Q1, Q3)

Significance

(p)

SFs

Non-SFs

SFs

Non-SFs

SFs

Non-SFs

Carbonated and

non-carbonated

beverages and

wine coolers

15

253

2 (1, 3)

0 (0, 2)

Positive

(.0005)

1 (1, 3)

0 (0, 1)

Positive

(.0002)

0 (0, 1)

0 (0, 0)

NS

(.094)

Juices, nectars

and fruit drink

substitutes

24

612

4 (3.5, 5)

2 (1, 3)

Positive

(<.0001)

3 (2, 4)

1 (1, 2)

Positive

(<.0001)

1 (1, 1)

0 (0, 1)

Positive

(.0015)

50

Table 12. Level of nutrition marketing on food labels of functional foods* (FFs) and non-functional foods (non-FFs) in Canada in 2013

Food subcategory*

FFs

(n)

Non-

FFs (n)

Total marketing

items¥

Mdn (Q1, Q3)

Significance

(p)ǂ

Regulated claims

Mdn (Q1, Q3)

Significance

(p)

FOPS

Mdn (Q1, Q3)

Significance

(p)

FFs

Non-FFs

FFs

Non-FFs

FFs

Non-

FFs

Cookies and graham

wafers

22

369

2.5 (2, 4)

0 (0,1)

Positive

(<.0001)

2 (1, 3)

0 (0, 1)

Positive

(<.0001)

1 (1, 1)

0 (0, 0)

Positive

(<.0001)

Grain-based bars

(with filling or

partial or full

coating)

33

73

2 (1, 2)

0 (0, 1)

Positive

(<.0001)

1 (1,2)

0 (0,1)

Positive

(<.0001)

1 (0, 1)

0 (0, 0)

Positive

(<.0001)

Grain-based bars

(without filling or

coating)

17

83

2 (2, 3)

1 (1, 2)

Positive

(.0008)

2 (1, 2)

1 (0, 2)

NS

(.06)

1 (0, 1)

0 (0, 1)

Positive

(.02)

Carbonated and non-

carbonated beverages

and wine coolers

14

254

2 (0, 3)

0 (0, 2)

Positive

(.02)

1 (0, 3)

0 (0, 1)

Positive

(.01)

0 (0, 1)

0 (0, 0)

NS

(.06)

Ready-to-eat

breakfast cereals

(puffed and coated,

without fruit or nut,

very high fibre)

19 58 6 (5, 7) 3 (1, 4)

Positive

(<.0001)

4 (3, 5)

2 (1, 3)

Positive

(.0004)

2 (1, 2) 1 (0, 1)

Positive

(.0005)

Ready-to-eat

breakfast cereals

(fruit and nut type,

granola, biscuit-type)

30

140

5 (4, 7)

4 (2, 6)

Positive

(.03)

3.5 (2, 6)

3 (1, 5.5)

NS (.11)

1 (1, 2)

1 (0, 1)

Positive

(.01)

51

Table 12. (continued)

* Functional foods (FFs) were defined as foods containing substances (other than vitamins and minerals) added for the purpose of providing a

health benefit. Food subcategories containing at least 10 FFs were analyzed. ¥ Total marketing items include the total number of regulated claims (i.e.

nutrient content claims and health claims) and Front-of-Pack systems (FOPS). Mdn represents median values. Q1 and Q3 represent 25% and 75% quartile

median values. ǂ p < 0.05 is considered significant. Positive significance denotes that FFs had a significantly greater number of total marketing/regulated

claims/FOPS than non-FFs. NS represents no significance.

Food subcategory*

FFs

(n)

Non-

FFs (n)

Total marketing

items¥

Mdn (Q1, Q3)

Significance

(p)ǂ

Regulated claims

Mdn (Q1, Q3)

Significance

(p)

FOPS

Mdn (Q1, Q3)

Significance

(p)

FFs

Non-FFs

FFs

Non-FFs

FFs

Non-

FFs

Pastas without sauce

23

416

3 (3, 4)

0 (0, 2)

Positive

(<.0001)

2 (1, 3)

0 (0, 2)

Positive

(<.0001)

2 (1, 2)

0 (0, 0)

Positive

(<.0001)

Plant-based

beverages, milk,

buttermilk, and milk-

based drinks

14

233

3 (3, 5)

2 (1, 4)

Positive

(.02)

3 (3, 5)

2 (1, 4)

NS

(.06)

0 (0, 1)

0 (0, 0)

NS

(.26)

Yogurt

74

159

2 (2, 3)

2 (1, 3)

Positive

(.005)

2 (2, 3)

2 (1, 2)

Positive

(.0003)

0 (0, 0)

0 (0, 0)

NS

(.24)

Juices, nectars, and

fruit drink substitutes

14

622

4 (3, 5)

1 (0, 2)

Positive

(<.0001)

3 (2, 3)

1 (0, 2)

Positive

(<.0001)

1 (1, 2)

0 (0, 1)

Positive

(<.0001)

52

3.5 Discussion

Part I of this study provides the first comprehensive analysis of the occurrence of supplemented

and functional foods in the Canadian market in 2013 and a summary of the types and amounts of

nutrients that are added to these foods. Both supplemented and functional foods made up a very

small proportion (less than 3%) of the total food market (n = 15,332).

However, when examined on a subcategory level, many food subcategories contained a large

proportion of functional foods, such as shakes and shake substitutes (36%), yogurts (32%), grain-

based bars (17-31%), and ready-to-eat breakfast cereals (18-25%). Supplemented foods were

much less common. Subcategories containing the greatest proportions of supplemented foods

were vegetable juice and drink (9%), carbonated and non-carbonated beverages and wine coolers

(6%), and juices, nectars, and fruit drink substitutes (4%). This analysis provides baseline data on

the occurrence of supplemented and functional foods in the Canadian market in 2013 and can be

used to track changes that occur over time, as nutritionally-enhanced foods are a fast-growing

sector of the food industry (26, 27) and as more products transition from NHPs to foods with

NFts.

Amongst supplemented foods, B vitamins were the most commonly added micronutrient. Most B

vitamins, with the exceptions of niacin/vitamin B1 and vitamin B6, do not have defined ULs, and

thus manufacturers have greater safety margins to add them to foods in large amounts. The

highest amount seen, in relation to the RDA, of any vitamin added to a supplemented food was

12 µg of vitamin B12, an amount that is 5 times the RDA for adults and nearly 7 times the RDA

for children. Amongst vitamins and minerals that have defined ULs, two foods were found to

contain levels of niacin/vitamin B1 that exceeded the UL of adults and would be nearly two

times the UL of children. The consumption of these foods may lead to negative symptoms

associated with excess intake of niacin, such as flushing, nausea, vomiting, and symptoms of

liver toxicity (78). Adverse health effects due to high intakes of vitamins and minerals are an

area of even greater concern in members of the population that have lower RDAs and ULs, such

as children under the age of 13, and if individuals are consuming more than the recommended

amount of these SFs, which is typically one to two servings per day, or those already consuming

supplements. However, in the TMAL guidance document for supplemented foods that was

53

released in February 2016, after this work was completed, iron and folic acid could no longer be

added to SFs and, using the newly developed two-path approach to setting maximum levels of

addition, added magnesium, calcium, zinc, and potassium in many of the products surveyed

would exceed Path 1 levels and thus cautionary statements would be required on such foods (20).

In addition to vitamins and minerals, many supplemented beverages contained high levels of

caffeine. Although maximum levels of caffeine addition to beverages have been set in documents

published by Health Canada (18), there is currently no safe level of caffeine consumption that

has been established for children and adolescents, and caffeinated beverages have been deemed

unsuitable for consumption in these populations (79). Children and adolescents are at higher risk

of developing caffeine toxicity, including serious side effects such as adverse cardiovascular

effects, seizures, and death (80). Although some SFs, particularly those containing high levels of

caffeine, are required to carry cautionary statements (18), such as ‘not recommended for persons

under 18 years of age’, these products are easily accessible to all members of the population, as

they are sold alongside other beverages in grocery stores, and the effectiveness of warning labels

in promoting safe consumption has not been extensively examined, although a recent study

shows that warning labels on energy drinks may lead to decreased consumption in adolescents

but not adults (81). As reports of adverse health effects associated with the consumption of

supplemented foods and beverages are increasing (82), it is an area of public health concern to

introduce methods to restrict the use of these products amongst susceptible members of the

population. In addition, it is necessary to conduct studies to track the consumption of SFs in the

Canadian population, in particular amongst children and adolescents, as there is currently no data

available on this topic. Unfortunately the CCHS 2015 will not be tracking consumption of these

products at the brand level, and given the wide range of addition between minimum and

maximum levels (e.g. niacin 5.8-39.1 mg, a 6.7 fold difference or vitamin B6 0.5-7.0 mg, a 14

fold difference) excess in some groups could be much higher than the general median in the

latest CNF 2015.

With regards to functional foods, the most commonly added substances were found to be

inulin—a novel and prebiotic fibre—and probiotic bacterial cultures. Consuming high doses of

inulin has been associated with short-term gastrointestinal side effects, such as bloating,

flatulence, and diarrhea (83), and although probiotics are generally well-tolerated amongst

54

healthy individuals, there are concerns surrounding an increased risk of sepsis if consumed by

particular high-risk populations, such as immunocompromised individuals (84). In addition,

functional foods containing high levels of protein isolates/concentrates may not be suitable for

consumption amongst certain individuals, such as those with compromised kidney function (85).

Despite these concerns, the functional foods that were surveyed in the present study generally

did not contain added substances that were associated with serious side effects. However, as the

functional food market continues to grow at an increasing rate, it is important to monitor FFs to

track the types of substances that continue to be added to foods. In addition, it would be useful to

survey the consumption patterns of functional foods amongst individuals in the Canadian

population to determine the extent to which FFs contribute to dietary fibre intakes, rather than

from traditional sources of dietary fibre such as fruits, vegetables, and whole grains

recommended by the Canadian Food Guide (66).

Part II of this study provides the first comprehensive assessment of the nutritional quality and

level and type of nutrition marketing of supplemented foods and functional foods in the

Canadian food market. Contrary to concerns raised by health professionals and others (5), we

found that SFs and FFs were either more healthy (i.e. had lower median scores) or as equally

healthy as foods without supplemented or functional ingredients when expressed at the

subcategory level. However, in 40% of the subcategories analyzed (4 out of 10 subcategories),

functional foods were rated as ‘less healthy’ foods that would not be permitted to carry health

claims under FSANZ, despite the fact that, in most cases, they were still healthier than the non-

functional foods in these subcategories. This finding suggests that many foods that are being

enhanced with functional ingredients are types of foods that generally have low nutritional value,

such as cookies and graham wafers, grain-based bars, and some ready-to-eat breakfast cereals.

This may be worrisome if consumers increase their consumption of certain types of foods that

have an overall poorer nutritional value, such as cookies and high-sugar cereals, if they contain

functional ingredients. A Canada-wide survey revealed that the majority of teens and adults

would be more likely to consume foods with low nutritional value, such as soft drinks and salty

snacks, if they were fortified with nutrients (71). A study conducted in 2004 found that Canadian

parents viewed the addition of vitamins and minerals to foods of poor nutritional quality as an

55

added bonus (72). Additionally, a conjoint study investigating Danish, Finnish, and American

consumer perceptions of functional foods found that the addition of substances such as

bioactives to foods was perceived as providing a greater health benefit when they were added to

conventionally ‘unhealthy’ foods, such as spreads, compared to ‘healthy’ foods, such as yogurt

(73).

Supplemented foods, on the other hand, seem to be an area of less concern, as they were deemed

sufficiently healthy (i.e. had NPSC scores within category-specific thresholds) to carry health

claims under FSANZ in both subcategories analyzed. This finding may be due to the fact that

there are fewer supplemented foods being sold in Canadian grocery stores (n = 52) than there are

functional foods (n = 326), and fewer types of foods are currently permitted to be supplemented,

namely beverages. It is still important to track the nutritional quality of supplemented foods in

the Canadian food supply over time as they gain popularity and become more widespread

amongst food categories, particularly as more natural health products in food format transition to

foods under the Health Canada regulatory framework (16).

It is important to note that both supplemented foods and functional foods in all subcategories

analyzed were more heavily marketed overall than comparable foods without supplemental or

functional ingredients, regardless of the nutrient profile scores of these foods. This finding

suggests that the level of marketing on foods with added ingredients is high and not indicative of

the overall nutritional quality of the food. This excessive marketing is an area of concern, since

Health Canada currently does not use a nutrient profiling system requiring foods that carry

nutrient content and health claims to meet minimum nutritional quality criteria, and there are no

specific regulations to govern the use of FOPS on food packaging. As a result, many foods of

poor nutritional quality, such as foods high in sugar or sodium, may carry a large array of

nutrition-related claims on their packaging. Combined with the result that nutrients are often

added to foods occurring in ‘less healthy’ food subcategories, this heavy marketing on products

with added nutrients may lead consumers to inadvertently make less healthy dietary choices, as

multiple studies have shown that consumers form more positive attitudes towards a product if it

carries health claims (41-44), especially if these claims appear on products that are commonly

perceived as ‘less healthy’ (47). Additionally, a study specifically examining the effect of health

claims appearing on functional food labels on consumer perceptions found that health claims had

56

a positive effect on consumers’ perceived healthiness of these products (73). To prevent the

misleading of consumers and potential negative effects on dietary patterns, Health Canada

should tighten the regulations governing nutritionally-enhanced foods, particularly those

surrounding functional foods, requiring foods to have overall ‘healthy’ nutrient profiles in order

to be permitted to contain added vitamins, minerals, bioactives, novel fibres, and other nutrients.

In addition, the use of nutrient content and health claims on food labels should be more strictly

regulated, and FOP systems and symbols should be included in the FDR, requiring that minimum

nutritional quality standards be met, in order to carry such claims, as is done in Australia, New

Zealand, Ireland, Norway, and other countries (1).

There are certain limitations to this study. First, the classification of foods as either supplemented

foods or functional foods were based on inclusion and exclusion criteria specific to this study,

since Health Canada had not yet provided finalized definitions or classification criteria for either

of these types of foods at the time the analyses were completed. In addition, a number of foods

that would be considered as SFs may not have been captured in this study because at the time of

collection of the FLIP 2013, many SFs had not made the full transition to the food regulatory

framework and did not yet carry a standardized NFt on their labels. Only SFs carrying a

standardized NFt were included in this study. As a result, the occurrence of SFs in the Canadian

food market is likely underestimated in this study.

In addition, it was assumed that the nutrient content information in the NFt used to calculate

FSANZ nutrient profiling scores was accurate. The accuracy of the NFt in reflecting the true

nutritional composition of foods is assessed by the Canadian Food Inspection Agency (CFIA)

and was found to be satisfactory for the majority of foods (86). However, the possibility remains

of unsatisfactory reporting of nutrient content values in the NFt of some products. Also, the

nutrient profiling model used to calculate the nutritional value of a food was originally created

for use in Australia and New Zealand, not Canada. However, as there is currently no validated

Canadian system that has been intended for use as a nutrient profiling model, the FSANZ model

was chosen as an appropriate substitute. Additionally, quantitative declaration of ingredients,

such as fruits, vegetables, nuts, and legumes, is not required to be provided by manufacturers on

food labels in Canada. Therefore, the fruit/vegetable/nut/legume (FVNL) content of a food could

not be directly determined to calculate the NPSC score. However, the rank of FVNL ingredients

57

in the Ingredients List was used to approximate the percentage of FVNL in a product, since

ingredients are listed by weight in descending order in the Ingredients list. Although this method

was standardized and the cutpoints are quite high, the FVNL content scores were still only

estimates and may lack complete accuracy. A final limitation to consider is that the NPSC

system considers saturated fat a ‘negative’ nutrient. However, the association between saturated

fat and the risk of chronic diseases, such as cardiovascular disease, is a controversial topic and

remains unclear (68).

Through the introduction of supplemented and functional foods, the food industry today has

greater freedom to add a variety of nutrients to foods, and consumers, in turn, have a wider range

of products to choose from to fulfill their dietary needs. However, the present study supports

concerns that: i) consumers may inadvertently consume nutritionally-enhanced products,

particularly SFs, in ways that may lead to adverse health effects, such as high intakes of

particular nutrients that are not appropriate for certain age groups (5); and ii) that the increasing

popularity of nutritionally-enhanced foods may lead consumers to overlook the overall

nutritional content of the foods they are purchasing, such as high levels of sugar and sodium, and

result in negative repercussions on population health.

The findings of this study can provide valuable information to researchers and the government to

aid in the creation of appropriate regulatory policies regarding nutritionally-enhanced products,

such as: the use of a validated nutrient profiling system to regulate the use of nutrition-related

marketing on food packages, as several other countries, such as the United Kingdom, Australia,

and New Zealand, have done; and governing the types of foods that may be permitted to contain

added nutrients. Additionally, new approaches should be made to guide consumers in the

appropriate use of nutritionally-enhanced foods and allow for their safe consumption. For

example, product specific labeling or logos can be used to help consumers distinguish products

with added nutrients from other foods. Further studies examining the consumption of brand

specific supplemented and functional foods in the Canadian population are required to further

analyze the extent to which these types of foods are contributing to nutrient intakes and affecting

the dietary patterns of Canadians.

58

Chapter 4

4 – Study 2: The nature and prevalence of voluntarily fortified

foods with high levels of added vitamins and minerals in the

Canadian marketplace

4.1 Abstract

Although the majority of Canadians have adequate intakes of most micronutrients (87), a variety

of foods in Canada are being voluntarily fortified with high levels of vitamins and minerals.

Researchers have raised concerns that the consumption of such foods may cause excessive

micronutrient intakes in certain population subgroups, such as children and adolescents; and that

food manufacturers are adding vitamins and minerals to foods that are otherwise unhealthy. The

objective of this study was to determine and measure the prevalence of voluntarily fortified foods

with high levels of vitamins and minerals (VHVMs) in the Canadian market (n = 15 332), their

nutritional quality, and their levels of nutrition-related marketing. A total of 923 foods were

classified as VHVMs. A wide range of food types, including ready-to-eat breakfast cereals, fruit

juices, nectars and fruit drinks, and plant-based beverages, contained high proportions of

VHVMs. Using the validated nutrient profiling model created by FSANZ, in 50% of the food

categories analyzed, VHVMs were less healthy than comparable foods without these

vitamin/mineral additions and in 25% of food categories, VHVMs were considered unhealthy

foods. Additionally, VHVMs carried more nutrition-related marketing claims than non-VHVMs

in all food categories. These findings provide baseline information on the prevalence and

attributes of VHVMs in Canada and support concerns surrounding the potential for fortified

foods to contribute to excess intakes of certain vitamins and minerals, such as folic acid and iron,

and the displacement of healthy foods. Further studies should be conducted to measure the

consumption of these foods in the Canadian population and evaluate the impact of VHVMs on

population health.

59

4.2 Introduction

In Canada, the fortification of foods with nutrients, such as vitamins and minerals, has

historically been used as a method to prevent and correct nutrient deficiencies in the population

and address the illnesses associated with them (7). When fortification was first introduced in the

1940s, it was hugely successful in eliminating nutrient-deficiency related illnesses, such as goitre

and rickets, in the population. Presently, however, vitamin and mineral deficiency is no longer

viewed as a pressing health issue, as the majority of Canadians are consuming most

micronutrients in adequate, and sometimes even excessive, amounts (87). Yet, the fortified food

market continues to grow and high levels of vitamins and minerals continue to be added to a

wide range of foods (25).

There are two forms of fortification defined in the Food and Drug Regulations (FDR):

mandatory fortification—which requires that certain micronutrients must be added to specific

foods, such as the addition of vitamin D to milk—and voluntary fortification—which allows for

a range of micronutrients to be voluntarily added to certain foods, such as the addition of B

vitamins to breakfast cereals (88). For both mandatory and voluntary fortification, vitamins and

minerals may be added to foods only in prescribed amounts laid out in the FDR (10). The

maximum levels of vitamin and mineral addition to foods are based on the highest

Recommended Daily Allowances (RDAs)/Adequate Intakes (AIs) and Tolerable Upper Levels

(ULs) within the population, typically values indicated for males 19 years of age and older (64,

77). However, voluntarily fortified foods, such as breakfast cereals and fruit juices, tend to be

marketed to all members of the population, including children (23). There is concern that this

method of setting maximum levels may potentially lead to excessive micronutrient intakes in

certain segments of the population, such as children (23, 25, 89).

Researchers and health professionals are also wary that manufacturers may use voluntary

fortification as a marketing strategy and add vitamins and minerals to foods that are less healthy

to increase sales (5, 89). Increased prevalence of voluntarily fortified foods of poor nutritional

value, particularly if combined with heavy marketing on the labels of such foods, may lead to the

displacement of ‘healthy’ foods and have significant negative impacts on the dietary patterns of

Canadians. Canadian studies have shown that adults and teens are more likely to increase their

60

consumption of less healthy foods, such as soft drinks and salty snacks, if they are fortified (71),

and that Canadian parents view the addition of vitamins and minerals to foods of low nutritional

quality as an added bonus (72). In addition, it has been shown that health claims on food labels

positively affect consumer attitudes towards a food (41-44), even if those foods have a ‘less

healthy’ image, such as candies and spreads (47). Although the FDR enforces specific

regulations surrounding the use of certain claims, such as nutrient content and health claims,

Canada currently does not use a nutrient profiling system requiring foods to have an overall

healthy profile to carry a claim. Additionally, there are no specific regulations governing the use

of FOP systems (FOPS) on food labels.

Although some studies have been conducted on the health outcomes of voluntary fortification in

other countries (24, 25), there is currently a lack of data on the occurrence and nature of

voluntarily fortified foods to test these hypotheses in Canada. The objectives of this study were

to assess the frequency and nutritional quality of voluntarily fortified foods with high levels of

added vitamins and minerals (VHVM) in the Canadian marketplace, as well as to determine if

such foods are more heavily marketed than other comparable foods without such additions.

4.3 Methodology

4.3.1 Data collection

Food Label Information Program 2013 (FLIP 2013)

Data was acquired using the University of Toronto Food Label Information Program 2013 (FLIP

2013), an online database containing 15,401 prepackaged foods and beverages from the top four

supermarket chains of Canada—Loblaws, Sobeys, Metro, and Safeway—and representing 75.4%

of the grocery retail marketshare (74). FLIP 2013 provides a cross-sectional nutritional overview

of prepackaged products in the Canadian marketplace in 2013. Complete details of the FLIP

2013 methodology can be found in Bernstein et al. (2016)(75).

10 products carried manufacturer labelling errors and were removed from the initial product

collection. Furthermore, meal replacements, foods intended for children under the age of 4, and

products lacking a standard Canadian NFt (e.g. Natural Health Products) were excluded from

this analysis, leaving a final sample of 15,332 products. The Nutrition Facts Table (NFt) and

61

Ingredients List of all remaining foods and beverages were examined to obtain information on

the type and amount of added ingredient in each product.

4.3.2 Data analysis

Classifying foods and beverages with high levels of voluntary fortification

In this study, a food or beverage was classified as having high levels of voluntary fortification

(VHVM) if it complied with the regulations pertaining to voluntary fortification in the FDR (10)

and it contained a vitamin or mineral in an amount that is greater than 25% of the Daily Value

(DV). Foods and beverages that did not contain added nutrients, contained added nutrients in

lower amounts (≤25% of the DV), or contained added nutrients for purposes other than voluntary

fortification (e.g. mandatory fortification or enrichment, or food additive purposes) were

excluded from this group and classified as non-VHVMs. All foods were categorized based on

food subcategories in Schedule M of the FDR (76).

Nutrient profiling

The validated Nutrient Profiling Scoring Criterion (NPSC) system, created by Food Standards

Australia New Zealand (FSANZ) (54), was used to create a nutrient profile score for each

product (Appendix 4). The FSANZ model separates foods into three categories: beverages

(Category 1); cheese, edible oil, edible oil spreads, butter and margarine (Category 3); and any

food other than those included in categories 1 and 3 (Category 2). A score is then created for

each food or beverage according to a points-based system relying on category-specific nutrient

content thresholds. Points are added for ‘negative’ nutrients, such as energy content, saturated

fat, total sugars, and sodium, and points are deducted for ‘positive’ nutrients, such as

fruit/vegetable/nut/legume, protein, and fibre content. Scores fall on a range of -18 to 81, with

lower scores indicating ‘healthy’ foods and higher scores indicating ‘less healthy’ foods. Foods

in categories 1, 2, and 3 are eligible to carry health claims under FSANZ only if their final scores

are less than 1, 4, or 28, respectively.

Marketing

All nutrition-related marketing on prepackaged products in FLIP 2013 were recorded and

classified into several categories, including regulated claims (i.e. nutrient content claims, disease

62

risk reduction claims, and function claims) and Front-of-Pack nutrition rating systems (FOPS).

Each regulated claim or FOPS was counted individually as one marketing item. If a product

repeated the same claim or FOPS multiple times on different panels, the claim or FOPS was

counted only once. The number of regulated claims, FOPS, and total marketing items occurring

on VHVMs were compared to non-VHVMs.

Statistical analyses

All statistical analyses were performed using SAS version 9.3 (Statistical Analysis Software Co,

Cary NC). Categorical variables are given as percentages and frequencies and continuous

variables are quantified as medians, Q1s, and Q3s. For food subcategories containing at least

10% of foods with high levels of voluntary fortification, the Wilcoxon signed rank test was used

to determine if there were any statistical differences in median NPSC scores compared to non-

VHVMs. Chi squared tests were used to compare the proportions of VHVMs and non-VHVMs

meeting ‘healthy’ cutpoints based on the FSANZ NPSC system to be eligible to carry health

claims. Additionally, the number of total marketing items, regulated claims, and FOPS between

VHVMs and non-VHVMs were compared within each food subcategory. A P value of <0.05

was considered significant.

4.4 Results

Frequency and proportion of VHVMs and most commonly added vitamins and

minerals

A total of 923 foods and beverages (6% of total database foods) were classified as VHVMs.

Major food categories containing the greatest number of VHVMs were cereals and other grain

products, and fruit juices (Table 13). Food subcategories containing the greatest proportions of

VHVMs were ready-to-eat breakfast cereals (puffed and coated, without fruit and nut) (77%),

fruit juices, nectars, and fruit juice substitutes (54%), vegetable juice and drink (47%), fruit

(fresh, canned, or frozen) (43%), plant-based beverages, milk, buttermilk, and milk-based

beverages (39%), hot breakfast cereals (37%), pastas without sauce (35%), and ready-to-eat

breakfast cereals (fruit and nut type, granola, biscuit type) (33%). The top five most commonly

added vitamins and minerals include vitamin C (n = 462), thiamine (n = 275), folic acid (n =

154), and iron (n = 156) (Table 14).

63

FSANZ nutrient profile scores of VHVMs in comparison to other foods

In four out of eight subcategories—hot breakfast cereals, ready-to-eat breakfast cereals (puffed

and coated, without fruit and nut, very high fibre), juices, nectars, and fruit-juice substitutes, and

fruits (fresh, canned, or frozen)—VHVMs had significantly higher (p<0.0001) NPSC scores (i.e.

were ‘less healthy’) than non-VHVMs within the same subcategories (Table 15). In two of these

subcategories—hot breakfast cereals and ready-to-eat breakfast cereals (puffed and coated,

without fruit or nut)—significantly greater proportions of VHVMs did not meet ‘healthy’

cutpoints compared to non-VHVMs (Table 16). Additionally, the median NPSC scores of

VHVMs in these subcategories deemed them ineligible to carry health claims, whereas the

median NPSC scores of non-VHVMs in the same subcategories were sufficient to allow these

foods to carry health claims.

In two out of eight subcategories—plant-based beverages, milk, buttermilk, and milk-based

drinks, and pastas without sauce—VHVMs had significantly lower (p<0.05) FSANZ NPSC

scores (i.e. were ‘more healthy’) than comparable non-VHVMs. Additionally, a significantly

greater proportion of VHVMs in the plant-based beverages, milk, buttermilk, and milk-based

drinks subcategory met cutpoints to be rated as ‘healthy’, in comparison to non-VHVMs in this

subcategory.

In the remaining two categories—ready-to-eat breakfast cereals (fruit and nut type, granola,

biscuit type) and vegetable juice and drink—there were no statistical differences in median

NPSC scores between VHVMs and non-VHVMs. There were also no statistical differences in

the proportions of VHVMs and non-VHVMs meeting ‘healthy’ cutpoints, with the majority of

both types of foods considered healthy in these subcategories. However, in the ready-to-eat

breakfast cereals (fruit and nut, granola, biscuit type) subcategory, there were still large

proportions of both VHVMs (37%) and non-VHVMs (34%) that did not meet the cutpoints to be

rated as ‘healthy’.

Marketing of VHVMs in comparison to other foods

In all eight subcategories, VHVMs had significantly greater (p<0.05) numbers of total marketing

items on product labels in comparison to non-VHVMs (Table 17). In all but two subcategories,

VHVMs carried a significantly greater number of regulated claims (i.e. nutrient content,

64

function, and disease risk reduction claims) than non-VHVMs, and in six out of eight

subcategories, a significantly greater number of FOPS occurred on the labels of VHVMs

compared to non-VHVMs.

65

Table 13. The prevalence of voluntarily fortified foods with high levels of added vitamins and

minerals (VHVMs) in the Canadian market in 2013

Food category

Total foods

N

Number of

VHVMs

n (% of total N)

Bakery products

Pies, tarts, cobblers, turnovers and other

pastries

101

3 (3)

Beverages

Carbonated and non-carbonated beverages and

wine coolers

268

8 (3)

Cereals and other grain products

Pastas without sauce

439

154 (35)

Ready-to-eat breakfast Cereals (puffed and

coated, without fruit or nuts, very high fibre)

77

59 (77)

Ready-to-eat breakfast cereals, (fruit and nut

type, granola, biscuit type)

170

56 (33)

Hot breakfast cereals

107

40 (37)

Dairy products and substitutes

Plant-based beverages, milk, buttermilk and

milk-based drinks, such as chocolate milk

247

97 (39)

Fruit and fruit juices

Juices, nectars and fruit drink substitutes

636

342 (54)

Fruit, fresh, canned, or frozen

278

120 (43)

Vegetables

Vegetable juice and vegetable drink

43

20 (47)

Combination Dishes

Not measurable with a cup

521

2 (<1)

66

Table 13. (Continued)

Food Category Total foods

N

Number of

VHVMs

n (% of total N)

Salads

Salads, such as egg, fish, shellfish, bean, fruit,

vegetable, meat, ham or poultry salad

47

1 (2)

Snacks

Chips, pretzels, popcorn, extruded snacks,

grain-based snack mixes, fruit-based snacks

562

13 (2)

Desserts

Custard, gelatin and pudding

395

7 (2)

67

Table 14. Vitamins and minerals present in VHVMs* in the Canadian market in 2013

*VHVMs were defined as foods containing greater than 25% of the Daily Value (DV) of an added

vitamin or mineral in accordance with voluntary fortification policies stated in the Canadian Food and

Drug Regulations (FDR).

¥ Major food categories containing at least 15 VHVMs were analyzed.

Food category¥

Vitamin/mineral

Number of VHVMs containing

nutrient (% of total VHVMs)

Cereals and other grain

products

Folic acid/folate

154 (50)

Thiamine

275 (89)

Iron

156 (51)

Magnesium

3 (<1)

Niacin/niacinamide

2 (<1)

Dairy products and

substitutes

Fruit and fruit juices

Vegetables

Vitamin B12

90 (92)

Calcium

84 (86)

Vitamin D

98 (100)

Riboflavin

2 (2)

Vitamin C

462 (100)

Vitamin C

20 (100)

68

Table 15. Comparison of FSANZ nutrient profiling scores* of VHVMs¥ and non-VHVMs in Canada in 2013.

Food subcategory

VHVMs (n)

Non-VHVMs (n)

Median nutrient profiling

score (Q1, Q3)ǂ

p-value

Direction of

significanceѱ

VHVMs

Non-VHVMs

Hot breakfast cereals

40

67

9 (5, 11)

-5 (-6, -3)

<.0001

Negative

RTE cereals (puffed and

coated, without fruit or

nuts, very high fibre)

59

18

13 (10, 15)

0.5 (0, 5)

<.0001

Negative

RTE cereals (fruit and

nut type, granola, biscuit

type)

56

114

2 (0, 8)

1 (-1, 8)

0.27

NS

Pastas without sauce

154

285

-4 (-6, -4)

-4 (-4, -3)

<.0001

Positive

Plant-based beverages,

milk, buttermilk, and

milk-based drinks

97

150

-1 (-2, 0)

0 (-1, 1)

<.0001

Positive

Juices, nectars, and fruit-

juice substitutes

342

294

0 (-1, 1)

0 (-6, 1)

<.0001

Negative

Fruits (fresh, canned, or

frozen)

120

158

-1.5 (-4, 0)

-2 (-8, 0)

0.002

Negative

Vegetable juice and drink

20

23

0 (-1, 0.5)

0 (-3, 1)

0.64

NS

69

* Nutrient profiling scores were based on the FSANZ NPSC system. ¥ VHVMs were defined as foods containing greater than 25% of the Daily Value (DV) of an

added vitamin or mineral in accordance with voluntary fortification policies stated in the Canadian Food and Drug Regulations. Food subcategories containing at

least a 5% proportion and a minimum of 10 VHVMs were analyzed. ǂ Q1 and Q3 represent 25% and 75% quartile median values. ѱ p < 0.05 was considered

significant. Positive significance signifies that median scores VHVMs are significantly lower (or “healthier”) than median score values of non-VHVMs. Negative

significance indicates that median scores of VHVMs are significantly higher (or “less healthy”) than non-VHVMs. NS denotes no significance in median score

values.ⱷ Products meeting specific cut points (beverages: <1; all other foods except for cheese, edible oil, edible oil spreads, margarine, or butter: <4) based on

the NPSC system are considered ‘healthy’ and would be permitted to carry a health claim in Australia/New Zealand

70

Table 16. Number and proportion of VHVMs* and non-VHVMs meeting ‘healthy’ cutpoints based on the FSANZ NPSC system¥.

Food subcategory

VHVMs (n)

Non-VHVMs (n)

Number of foods meeting ‘healthy’ cutpoints

(%)

p-valueǂ

VHVMs

Non-VHVMs

Hot breakfast cereals

40

67

10 (25)

61 (91)

<.0001

RTE cereals (puffed and coated,

without fruit or nuts, very high fibre)

59

18

6 (10)

13 (72)

<.0001

RTE cereals (fruit and nut type,

granola, biscuit type)

56

114

35 (63)

75 (66)

0.67

Pastas without sauce

154

285

154 (100)

281 (99)

0.14

Plant-based beverages, milk,

buttermilk, and milk-based drinks

97

150

92 (95)

91 (61)

<.0001

Juices, nectars, and fruit-juice

substitutes

342

294

210 (61)

189 (64)

0.45

Fruits (fresh, canned, or frozen)

120

158

120 (100)

156 (99)

0.22

Vegetable juice and drink

20

23

15 (75)

16 (70)

0.69

* VHVMs were defined as foods containing greater than 25% of the Daily Value (DV) of an added vitamin or mineral in accordance with voluntary fortification

policies stated in the Canadian Food and Drug Regulations. Food subcategories containing at least a 5% proportion and a minimum of 10 VHVMs were

analyzed. ¥ Products meeting specific cut points (beverages: <1; all other foods except for cheese, edible oil, edible oil spreads, margarine, or butter: <4) based

on the FSANZ NPSC system are considered ‘healthy’ and would be permitted to carry a health claim in Australia/New Zealand. ǂ p < 0.05 was considered

significant.

71

Table 17. Levels of nutrition marketing on VHVMs* compared to non-VHVMs in Canada in 2013.

Food subcategory

VHVMs

(n)

Non-

VHVMs

(n)

Total marketing items

Mdn (Q1, Q3)¥

Significance

(p)ǂ

Regulated claims

Mdn (Q1, Q3) ¥

Significance

(p)ǂ

FOPS

Mdn (Q1, Q3) ¥

Significance

(p)ǂ

VHVMs

Non-

VHVMs

VHVMs

Non-

VHVMs

VHVMs

Non-

VHVMs

Hot breakfast cereals

40

67

5 (3, 5)

1 (0, 3)

Positive

(<.0001)

3 (2, 4)

1 (0, 3)

Positive

(<.0002)

1 (1, 2)

0 (0, 1)

Positive

(<.0001)

Ready-to-eat

breakfast cereals

(puffed and coated,

without fruit or nuts,

very high fibre)

59

18

4 (2, 6)

2 (1, 4)

Positive

(.02)

3 (2, 4)

2 (1, 3)

Positive

(.007)

1 (0, 2)

1 (0, 1)

NS

(.30)

Ready-to-eat

breakfast cereals

(fruit and nut type,

granola, biscuit type

cereals)

56

114

4 (2, 6)

3 (2, 4)

Positive

(.04)

3 (1.5, 4)

2 (1, 4)

NS

(.20)

1 (0, 2)

0.5 (0, 1)

Positive

(.002)

Pastas without sauce

154

285

1 (0, 3)

0 (0, 1)

Positive

(<.0001)

1 (0, 2)

0 (0, 1)

Positive

(<.0001)

0 (0, 1)

0 (0, 0)

Positive

(<.0001)

Plant-based

beverages, milk,

buttermilk, and milk-

based drinks

97

150

4 (3, 5)

2 (1, 3)

Positive

(<.0001)

4 (3, 5)

2 (1, 3)

Positive

(<.0001)

0 (0, 1)

0 (0, 0)

Positive

(.0009)

Juices, nectars, and

fruit-juice substitutes

342

294

2 (1, 3)

1 (0, 2)

Positive

(<.0001)

2 (1, 2)

1 (0, 2)

Positive

(<.0001)

1 (0, 1)

0 (0, 1)

Positive

(.0006)

Fruit (fresh, canned,

or frozen)

120

158

2 (0, 3)

1 (0, 2)

Positive

(.03)

0 (0, 1)

0 (0, 2)

NS

1 (0, 1)

0 (0, 1)

Positive

(.0003)

72

* VHVMs were defined as foods containing greater than 25% of the Daily Value (DV) of an added vitamin or mineral in accordance with voluntary fortification

policies stated in the Canadian Food and Drug Regulations. Food subcategories containing at least a 5% proportion and a minimum of 10 VHVMs were analyzed.

¥ Mdn represents median values; Q1 and Q3 represent 25% and 75% quartile median values. ǂ p < 0.05 was considered significant. Positive significance indicates

that VHVMs have a significantly higher median number of total marketing items/regulated claims/FOP than non-VHVMs. NS denotes no significant differences.

Vegetable juice and

vegetable drink

20

23

4.5

(2.5, 6.5)

1 (0, 4)

Positive

(.0005)

4 (2.5, 4)

1 (0, 3)

Positive

(.0005)

1 (1, 2)

1 (0, 1)

NS

(.08)

73

4.3 Discussion

This study provides the first comprehensive analysis of the frequency, nutritional quality, and

marketing characteristics of voluntarily fortified foods with high levels of added vitamins and

minerals (VHVMs) in the Canadian food market. Overall, over 900 foods and beverages

(approximately 6% of the food supply) contained voluntarily added vitamins and minerals in

high amounts (i.e. greater than 25% of the Daily Value). However, a number of food categories,

such as ready-to-eat breakfast cereals, plant-based beverages and milk-based drinks, and fruit

juices, nectars, and fruit juice substitutes, contained large proportions of VHVMs. These findings

confirm that many voluntarily fortified foods occur in food categories, such as breakfast cereals

and fruit juices, that are marketed towards all members of the population, including children

(23). Additionally, it should be noted that all of the food categories that contained high

proportions of VHVMs are among the top food choices of Canadian children and adolescents

(90, 91). The most commonly added vitamins and/or minerals in VHVMs were vitamin C,

thiamine, folic acid/folate, iron, and vitamin D, while vitamins and minerals that were added less

commonly (less than 10% of VHVMs) include vitamin B12, calcium, magnesium, niacin, and

riboflavin. Based on data from the Canadian Community Healthy Survey (CCHS) 2.2, the

prevalence of inadequacy for vitamin C, thiamine, folic acid, and iron was very low in Canadian

children and adolescents 13 years of age and under in 2004 (87). In individuals over the age of

14, the prevalence of inadequate vitamin/mineral intakes were uniformly high only for vitamin

A, vitamin D, calcium, and magnesium (87). Therefore, with the exception of vitamin D, most of

the vitamins and minerals that were most commonly added to VHVMs do not have evidence of

inadequacy in the Canadian population.

Researchers and health professionals are concerned that increased consumption of voluntarily

fortified foods may result in excessive nutrient intakes, especially in combination with

supplement use, in certain age/gender groups such as children (5, 89). In Canada, the use of

supplements is associated with an increased risk of vitamin/mineral intakes above the UL in both

children and adults (87), particularly in the cases of folic acid (92), zinc, and iron (87). Since

40% of Canadians take some form of vitamin/mineral supplement (87), the combined intake of

vitamins/minerals from both voluntarily fortified foods and supplements presents a real concern.

A recent study in the United States (25) found that higher exposure to voluntarily fortified foods

74

was associated with an increased risk of excessive nutrient intakes in children. It would be useful

to carry out a parallel study (25) in Canada, to analyze the extent to which voluntarily fortified

foods have the potential to lead to excessive nutrient intakes in the Canadian population,

particularly in children and adolescents.

In terms of comparing the nutritional quality of foods with high levels of voluntary fortification

to that of foods without such vitamin/mineral additions, this study found when median NPSC

scores were compared, 50% of food subcategories contained VHVMs that were significantly less

healthy than non-VHVMs. Additionally, in 25% of food subcategories, most VHVMs were not

rated as healthy foods and would not be permitted to carry health claims under FSANZ, whereas

most non-VHVMs in these categories were rated as healthy and would be able to carry health

claims. We also found that in an equal proportion (50%) of food subcategories, VHVMs were

either significantly healthier than or as equally healthy as comparable foods without high levels

of voluntary fortification. However, large proportions of VHVMs in some of these subcategories,

such as certain ready-to-eat breakfast cereals, still would not meet cutoffs to carry health claims,

despite the fact that they were not overall less healthy than comparable non-VHVMs.

Taken together, these findings suggest that: the voluntary addition of vitamins and minerals to

foods does not seem to have any strict correlation with the overall healthiness of a food; that a

large proportion of foods with high levels of voluntary fortification are less healthy than non-

voluntarily fortified foods; and that many foods with high levels of voluntary fortification would

not be considered healthy enough to carry health claims in countries that use nutrient profiling

models to regulate the use of health claims on food labels, such as Australia and New Zealand

(54). These results support the concern that consumers may inadvertently be choosing foods that

are less healthy under the false assumption that fortified foods are healthier than regular foods

because of their added vitamins and minerals (5). These concerns carry even more weight when

the high amount of marketing on voluntarily fortified foods is considered. In all food

subcategories analyzed, VHVMs, regardless of overall nutritional quality, were significantly

more heavily marketed—most carrying both a greater number of regulated claims and FOPS—

than foods without these nutrient additions. As previously mentioned, studies have shown that

Canadian consumers are more likely to include foods of low nutritional value in their diets if

they are fortified (71), and that they are more likely to form positive attitudes towards a food—

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including attitudes regarding the healthiness of a food—if the food label carries nutrition or

health-related claims (41, 42). Collectively, the findings from this analysis and other studies

support taking a cautious attitude towards the widespread addition of high levels of vitamins and

minerals to foods.

To prevent the shifting of dietary patterns and the displacement of healthy foods, the overall

nutritional quality of a food should be taken into consideration in setting regulations for the

marketing of voluntarily fortified foods. In the United Kingdom, Australia, and New Zealand,

nutrient profiling models that take into account various nutritional aspects of a food—such as

energy, saturated fat, sugar, and sodium content—are used to determine the eligibility of

products to carry nutrition-related and health claims. Currently, Health Canada does not use a

nutrient profiling system to regulate the use of nutrient content and health claims. In addition,

there are no specific regulations in Canada overseeing the use of FOP marketing on foods.

There are certain limitations to this study. First, the food database used in this analysis, FLIP

2013, represents approximately 75% of the market share in Canada (cite study 1). Therefore,

there is a certain percentage of foods in the food supply that have not been accounted for in this

analysis. Second, the nutrient content values used to calculate FSANZ nutrient profiling scores

were based on values found in the NFt on product labels, and it was assumed that this data were

accurate. The Canadian Food Inspection Agency (CFIA) uses a compliance test to assess the

accuracy of nutrient levels provided in the NFt by food manufacturers. An analysis of over 1000

foods sampled by the CFIA between 2006 and 2010 found that 16.7% of products were

unsatisfactory with regards to the accuracy with which certain nutrients, such as sodium, sugar,

and saturated fat, were reported in the NFt (86). Although the present study analyzed products

found in the market in 2013, the possibility remains that the NFt on some products may have

provided inaccurate values. In addition, the points scored for the fruit/vegetable/nut/legume

content of a product were based on the rank of ingredients in the Ingredients List, since

manufacturers are not required to provide this information in the NFt in Canada (Appendix 1).

Although the procedure was standardized (Appendix 1) and the cutpoints used were high, the

fruit/vegetable/nut/legume content of a product could only be estimated and these estimations

may lack complete accuracy. Finally, although the FSANZ nutrient profiling model has been

validated in Australia and New Zealand (1, 57), the model has not yet been validated for use in

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the Canadian market. However, as Health Canada has yet to release a validated classification

system intended for use as a nutrient profiling model, the FSANZ model was determined to be

the most appropriate model available to use in this analysis. Also, a final limitation to consider is

that the NPSC system considers saturated fat a ‘negative’ nutrient. However, the association

between saturated fat and the risk of chronic diseases, such as cardiovascular disease, is a

controversial topic and remains unclear (68).

The introduction of vitamin and mineral food fortification in Canada was one of the most

successful public health campaigns in the country and eradicated a wide array of diseases

associated with nutrient deficiencies, such as rickets and goitre (7, 8). However, the dietary and

health issues that most Canadians face today are no longer the result of a low intake of nutrients,

but rather an excessive intake of nutrients, along with rising rates of overweight and obesity in

both adults and children (2, 93). The voluntary fortification of a wide range of foods, many of

which have high levels of sugar, fat, and/or sodium, may be putting Canadians at risk of excess

nutrient intakes, such as folic acid and iron. Results from this study support the concern that

foods with added vitamins and minerals may inadvertently cause consumers to overlook the

levels of other nutrients in a food, such as sugar, fat, and sodium, and make unhealthy dietary

choices. To prevent the shifting of dietary patterns that may contribute to negative health effects,

such as obesity, Canada should follow the lead of other countries and enforce a nutrient profile-

based policy to restrict the range of foods that may contain added nutrients and govern the use of

nutrition-related marketing on the labels of voluntarily fortified foods.

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Chapter 5

5 - General Discussion

This is the first known set of studies investigating the prevalence and nature of nutritionally-

enhanced foods in Canada. This thesis aimed to conduct a comprehensive analysis on

supplemented foods, functional foods, and voluntarily fortified foods using the FLIP 2013, a

food database containing information on over 15,000 foods in the Canadian marketplace in 2013.

5.1 Overview of findings

Study 1

The overall frequency of SFs and FFs in the FLIP 2013 was relatively low (less than 3% of total

foods), with SFs (n = 52) being even less common than FFs (n = 326). However, the distribution

of SFs and FFs was not uniform amongst food categories, with certain subcategories containing

large proportions of foods classified as SFs or FFs. Categories containing the greatest

proportions of SFs included vegetable juices and drinks (9%), carbonated and non-carbonated

beverages and wine coolers (6%), and juices, nectars, and fruit drink substitutes (4%), while

categories containing the largest proportions of FFs included shakes and shake substitutes (36%),

yogurts (32%), grain-based bars (up to 31%), and ready-to-eat breakfast cereals (up to 25%).

The most commonly added micronutrients in SFs were B vitamins, caffeine, and taurine. In

many SFs, B vitamins were added in amounts several times the RDA of children and/or adults,

and in two cases, niacin/vitamin B1 were added in an amount exceeding the UL of both children

and adults. The highest levels of caffeine and taurine found in SFs were 360 ppm and 2000

mg/serving, respectively. The most commonly added functional ingredients in FFs included

novel fibres, such as inulin, and probiotic bacterial cultures. Other ingredients added to FFs

included herbals and bioactives such as ginseng extract, added proteins such as soy and whey

protein concentrates, novel ingredients such as plant sterols, and omega-3/omega-6 fatty acids

such as DHA oil.

Most SFs analyzed in the FLIP 2013 had median FSANZ NPSC scores meeting cut-offs to be

considered as ‘healthy’ foods. In addition, SFs were either healthier than or as equally healthy as

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non-SFs in the subcategories examined, when median NPSC scores were compared between the

two groups. For FFs, 4 out of 10 food subcategories analyzed had median nutrient profiling

scores that rated them as ‘less healthy’ foods, and would not be permitted to carry health claims

under the FSANZ model. In 3 out of these 4 subcategories, FFs were still significantly healthier

(i.e. had lower median NPSC scores) than non-FFs in these subcategories, despite being rated as

‘less healthy’ foods. This finding suggests that many FFs are found in food subcategories that

generally contain foods that are not considered healthy, such as cookies and wafers, and some

types of ready-to-eat breakfast cereals. This may negatively affect the dietary patterns of

consumers as studies have found that consumers are more likely to choose foods from unhealthy

food categories, such as sugary beverages and salty snacks, if they contain added nutrients (71).

FFs in remaining food subcategories (6 out of 10) had median NPSC scores signifying that they

were healthy.

Both SFs and FFs were more heavily marketed than foods without added supplemental or

functional ingredients in all food subcategories analyzed, regardless of nutritional quality. In

several subcategories, SFs and FFs contained a greater number of both government regulated

claims (i.e. nutrient content and health claims) and FOP claims, and in other subcategories they

carried either a larger number of government regulated claims or FOP claims, but not both.

Study 2

Over 900 prepackaged food products in the FLIP 2013 contained high levels (>25% DV) of

voluntarily added vitamins and minerals. A wide range of foods, including breakfast cereals,

plant-based beverages and milk-based drinks, and fruit juices, nectars, and fruit juice substitutes,

contained large proportions (as high as 77%) of foods with high levels of voluntary fortification

(VHVMs).

In addition, VHVMs were less healthy than foods without high levels of voluntary fortification

in 50% (4 out of 8) food subcategories, based on median FSANZ nutrient profiling scores. In two

of these subcategories—hot breakfast cereals and ready-to-eat breakfast cereals (puffed and

coated, without fruit or nuts, very high fibre)—VHVMs had nutrient profiling scores that were

considered unsatisfactory for carrying health claims under FSANZ, while non-VHVMs in these

subcategories were considered healthy enough to carry health claims. In the remaining food

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subcategories, both VHVMs and non-VHVMs had median nutrient profiling scores meeting cut-

offs to classify them as healthy foods.

Foods with high levels of voluntary fortification were more heavily marketed than foods without

high levels of voluntary fortification in all food subcategories analyzed, irrespective of

nutritional quality. In all but two subcategories, VHVMs had greater numbers of both

government regulated claims (i.e. nutrient content and health claims) and FOP systems and

symbols than non-VHVMs.

5.2 General discussion

The health problem that Canadians face today is very different than what they faced when

policies regarding the addition of nutrients to foods were first proposed. In the early 1900s,

diseases such as rickets, goitre, and beriberi were widespread in the Canadian population due to

the limited availability of foods naturally containing adequate levels of essential nutrients, such

as vitamins and minerals (8). As a result, the mandatory fortification of foods with vitamins,

minerals, amino acids, and other micronutrients was successfully introduced in the 1940s to

reduce the prevalence of deficiency-related diseases and curb nutrient inadequacy in the

population. Since then, regulations have been revised and new policies created to allow for a

greater variety of foods to contain added nutrients and to promote the emergence of new foods.

However, micronutrient inadequacy is no longer a pressing issue in Canada. In fact, most

Canadians today are facing the opposite problem, dealing with an excess of nutrients rather than

an insufficiency. The majority of Canadians have energy intakes that exceed their needs and

consume sodium in amounts that are above the UL, and a large proportion of Canadians have fat

intakes that are above the AMDR (94). Regulations permitting the sale of a wide variety of foods

containing high levels of added nutrients may put Canadians at risk of excess intakes of both

micronutrients, such as vitamins and minerals, and macronutrients, such as fat and sugar.

In terms of excess micronutrient intakes, the findings from the studies conducted in this thesis

show that a large proportion of SFs contain vitamins and minerals, such as B vitamins, that have

no evidence of inadequacy in the Canadian population (29), and that many SFs contain these

micronutrients in levels that are above the RDA and/or UL. In addition to containing high levels

of added vitamins and minerals, a large proportion (61%) of SFs contained very high levels of

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caffeine (up to 360 ppm/serving) and the amino acid taurine (up to 2000 mg/serving). Although

maximum levels based on safety assessments have been established in Category Specific

Guidance Documents (18, 19) for the addition of caffeine and amino acids to certain foods such

as energy drinks, there is currently no established safe level of caffeine consumption for children

and adolescents. These population subgroups are at greater risk for developing serious adverse

effects associated with caffeine toxicity, such as heart palpitations, seizures, and death (79). SFs

containing high levels of caffeine are required to carry cautionary statements, such as ‘not

recommended for persons under 18 years of age’, on food labels (18). However, these products

are sold alongside other beverages and are easily accessible to all members of the population. In

addition, the effectiveness of cautionary labels in preventing inappropriate consumption of

caffeinated energy drinks in the Canadian population has not been examined, although one study

conducted in the US found that certain warning labels may be associated with decreased

consumption of energy drinks in adolescents (81). The consumption patterns of caffeinated

beverages among children and adolescents in the Canadian population is currently unknown,

although the number of cases of caffeine toxicity reported in these population subgroups

worldwide has been increasing (79).

Despite the fact that a large proportion of SFs were found to contain very high levels of added

substances, the overall prevalence of SFs in Canadian grocery stores is currently quite low; only

52 foods were classified as SFs in 2013. This may be due to tighter restrictions surrounding the

types of foods that are currently permitted to be supplemented, in comparison to the wide range

of foods that are permitted to contain functional ingredients or added micronutrients through

voluntary fortification. However, SFs are becoming increasingly popular, as the nutritionally-

enhanced food market is soaring in revenue worldwide (27), and may become more widely

distributed in the Canadian marketplace overtime.

Foods containing high levels of vitamins and minerals added through voluntary fortification are

much more prevalent than SFs, with over 900 prepackaged foods and beverages in the FLIP

2013 classified as VHVMs. Many food categories that are marketed to and consumed by all

members of the population and highly consumed by children and adolescents (90, 91), such as

breakfast cereals and fruit juices, nectars and fruit drink substitutes, contain large proportions (as

high as 77%) of foods that have been voluntarily fortified with high amounts (>25% DV) of

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vitamins and minerals, such as vitamin C, thiamine, folic acid, and iron. A recent analysis

conducted in the US found that individuals, including children, with greater exposure to

voluntarily fortified foods were at higher risk of having micronutrient intakes above the UL (25).

The potential for voluntarily fortified foods to contribute to excess intakes amongst Canadians is

an even greater concern in individuals taking vitamin and mineral supplements. Findings from

the CCHS 2.2 showed that a large proportion (40%) of Canadians take some form of a

vitamin/mineral supplement, and that supplement use is associated with an increase in the

percentage of vitamin/mineral intakes greater than the UL amongst all sex/age groups (87). This

is particularly concerning in the case of folic acid, one of the most commonly added vitamins in

VHVMs, considering that 40% of Canadians have been found to have high folate status(92).

Unlike SFs and VHVMs, the FFs (n = 326) analyzed in this thesis generally did not contain

substances that may cause harm if taken in excess. Some commonly occurring functional

ingredients in these foods were novel fibres, such as inulin, and probiotics. Aside from certain

mild symptoms, such as bloating, these substances are generally not known to have adverse

effects when taken in high amounts. However, as FFs are gaining popularity and becoming more

widespread, it is important to keep track of the types of substances that are being added to these

foods over time.

The findings from this thesis support concerns that the consumption of nutritionally-enhanced

foods—in particular SFs and VHVMs—may significantly increase the likelihood of excess

micronutrient intake amongst individuals in the Canadian population, particularly in individuals

taking supplements and in subgroups that have lower nutrient requirements, such as children.

The potential health effects resulting from excess micronutrient intakes can be very serious. High

intakes of vitamins and minerals have been associated with a wide array of short-term and long-

term detrimental effects, ranging from nausea and flushing of the skin to increasing risk of

certain types of cancer (95) and promoting obesity (96); and excessive caffeine consumption

may to lead to adverse cardiovascular effects, seizures, and death, particularly in children and

adolescents (79). To appraise the extent to which foods with added nutrients may have the

potential to contribute to excessive nutrient intakes, a nationwide survey capturing brand names

of foods to determine the consumption of supplemented and voluntarily fortified foods in the

Canadian population and measure the micronutrient intakes of various population subgroups,

82

including children, is needed. If such a survey reveals an association between the consumption of

supplemented and voluntarily fortified foods and the risk of nutrient intakes about the UL, it may

be necessary for the Canadian government to re-evaluate its regulations surrounding the addition

of micronutrients to foods, such as lowering the levels of vitamins, minerals, caffeine, and amino

acids that are currently permitted to be added to supplemented foods and reducing the range of

foods that may be voluntarily fortified.

In addition to reassessing existing regulations, it is also important to inform and educate

consumers about the appropriate consumption of nutritionally-enhanced foods. Foods and

beverages containing added nutrients are referred to in different terms depending on the type and

amount of added substances they contain. However, to consumers, these foods are mostly

indistinguishable from conventional foods, as they currently lack a product identifier and are sold

side-by-side other foods in grocery stores. The NFt is the main source of information regarding

the micronutrient content of a food that consumers currently have access to on the food label.

However, studies have shown that the NFt does not fully enable Canadian consumers to make

healthy dietary choices (33), and that many consumers may not be using or accurately

understanding the NFt (97). In addition, as was shown here, foods with added nutrients are

heavily marketed, and the presence of multiple claims on a product label may add to consumer

confusion (98). The Canadian government should provide consumers with simple and easily

accessible tools that will allow consumers to identify nutritionally-enhanced foods and to make

informed food choices and prevent excessive or inappropriate consumption of these foods.

The addition of vitamins, minerals, bioactives, and other substances to a food may also cause

consumers to overlook the levels of other nutrients, such as sugar, fat, and sodium, present in the

food and potentially alter the eating habits of Canadians to include more unhealthy foods. A

Canada-wide survey found that the majority of consumers would increase their consumption of

foods of otherwise poor nutritional quality, such as salty snacks and fruit-flavoured drinks, if

they contained added vitamins and minerals, and that a large proportion of parents would provide

more of these foods to their children (71). In addition, focus group data found that Canadian

consumers perceived the fortification of unhealthy foods with vitamins and minerals as an

‘added bonus’ (72). International data has shown that the enrichment of foods with substances

such as bioactives is perceived as providing a greater health benefit when these substances are

83

added to foods recognized as ‘unhealthy’, such as spreads, compared to foods perceived as

‘healthy, such as yogurt (73).

Findings from Studies 1 and 2 revealed that many nutritionally-enhanced foods, particularly FFs

and VHVMs, would not be considered as ‘healthy’ foods according to the validated FSANZ

nutrient profiling model (1, 54, 57), due to having high levels of ‘negative’ nutrients—such as

saturated fat, sugar, and sodium—and/or low levels of ‘positive’ nutrients—such as protein,

fibre, and fruits/vegetables/nuts/legumes. The median scores of FFs in a large proportion of food

subcategories, such as cookies and wafers and some breakfast cereals, did not meet cut-offs to be

considered healthy. However, FFs were still scored as ‘more healthy’ or ‘equally healthy’ than

conventional foods without functional ingredients in these subcategories. This suggests that, in

many cases, functional ingredients are being added to foods in food categories that are generally

considered unhealthy. VHVMs, on the other hand, not only failed to meet score cut-offs to be

considered healthy, they were also significantly less healthy than non-VHVMs in several food

subcategories. This finding suggests that, in several cases, the addition of vitamins and minerals

to foods is made to the least healthy foods within a food category. SFs were the only types of

nutritionally-enhanced foods that met score cut-offs to be considered ‘healthy’ in both food

subcategories analyzed. This partly may be due to the fact that far fewer and a smaller range of

SFs were found in the FLIP 2013 compared to FFs and VHVMs.

Marketing analyses found that SFs, FFs, and VHVMs carried significantly greater numbers of

nutrition-related claims than foods without added nutrients in all food subcategories analyzed,

regardless of the nutritional quality of these foods. Foods with added nutrients in many food

subcategories had higher numbers of both government-regulated claims (i.e. nutrient content and

health claims) and FOP systems/symbols. Multiple studies have shown nutrition-related claims

positively affect consumer attitudes towards a food (41-44, 46), and that this effect is more likely

to occur if claims appear on products that are generally perceived as ‘less healthy’, such as

candies and spreads (47). In addition, a conjoint study specifically examining Danish, Finnish,

and American consumers’ perceptions of functional foods found that health claims appearing on

food labels had a positive effect on the perceived healthiness of functional foods (73). The

combined effects of adding vitamins, minerals, and substances to foods of low nutritional value

and heavy marketing on these products may have the potential to lead consumers to inadvertently

84

make unhealthy dietary choices and have significant negative impacts on the dietary patterns of

Canadians. To further investigate the issue, a mock-package experiment should be conducted to

evaluate consumer attitudes and decision making towards supplemented, functional, and

voluntarily fortified foods with various nutrient profiles and marketing levels.

Several countries, including the United Kingdom, Ireland, Australia, New Zealand, Denmark,

and Norway, have used nutrient profiling to either restrict the types of foods that may carry

health claims or regulate the marketing of foods to children to combat rising rates of obesity and

diet-related noncommunicable disease (NCDs) (1). Despite also facing these same health issues,

Canada currently does not use a nutrient profiling model to regulate the marketing of food

products, meaning that foods may carry various types of claims, such as nutrient content and

function claims, and FOP marketing on their labels, despite having poor nutritional quality. The

combined findings of this thesis and other studies (71, 72) support the need for Health Canada to

use a validated nutrient profiling system to limit the types of foods that may contain added

nutrients and restrict the types of marketing that may appear on these foods, since it was found

that: i) many foods with added nutrients, in particular FFs and VHVMs, have otherwise poor

nutritional value; and ii) that foods with added nutrients carry high numbers of nutrition-related

claims, despite the fact that a large proportion of them are unhealthy and/or less healthy than

conventional foods.

5.3 Conclusion

Since the initial introduction of mandatory fortification in the 1940s, policies surrounding the

addition of nutrients to foods in Canada have constantly been undergoing change. Traditionally,

nutrients such as vitamins and minerals have been added to foods for purposes such as reducing

the incidence of deficiency-related diseases or preventing the prevalence of inadequate nutrient

intakes in segments of the population. Today, however, there is an extensive range of

nutritionally-enhanced foods available to consumers, including voluntarily fortified foods,

supplemented foods, and functional foods, and they are a fast-growing sector of the food

industry, both within Canada and globally. The growth in the supplemented, functional, and

fortified food market has been largely attributed to an increase in health consciousness of

85

consumers and the desire to maintain or improve physical and mental well-being. However, this

thesis found that many nutritionally-enhanced foods, including supplemented foods, functional

foods, and foods with high levels of voluntary fortification, contain high levels of nutrients that

do not have evidence of inadequate intake in the Canadian population or are necessary to

maintain or improve health. In addition, a large proportion of these foods were found to have

poor nutrient profiles and contain high levels of marketing, regardless of their nutritional quality.

As the nutritionally-enhanced food market is growing and these foods become more widely

available to consumers, a number of issues regarding the consumption of foods with added

nutrients warrant attention, such as high intakes of nutrients that exceed ULs and the negative

shifting of dietary patterns to include more unhealthy foods. To further evaluate these concerns,

studies should be conducted to investigate consumer attitudes and decision-making towards SFs,

FFs, and VHVMs. The combined findings of such studies and this thesis can be used to inform

and aid the Canadian government in creating an appropriate regulatory framework for foods with

added nutrients and taking other measures, such as consumer education campaigns or product

specific labeling or logos to help consumers identify such products, to allow for the safe

consumption of these foods to protect the health and well-being of Canadians. In addition, the

prevalence and nature of foods with added nutrients in the Canadian marketplace should be

closely monitored over time to investigate any potential changes that may occur, particularly as a

large number of NHPs become recognized as foods (16), which were not captured in this study.

86

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94

Appendices

Appendix 1. Method for calculating FVNL content of foods using the Ingredients List

95

Appendix 2. Ingredients that can be added to nutritionally-enhanced foods*

Supplemented foods

Vitamins: Biotin, folic acid/folate, niacinamide/nicotinamide, nicotinic acid/niacin, pantothenic

acid/d-calcium pantothenate, riboflavin/vitamin B2, thiamine/vitamin B1, vitamin

A/retinol/retinyl palmitate/retinyl acetate/beta-carotene, vitamin

B12/cyanocobalamin/methylcobalamin, vitamin B6/pyridoxine, vitamin C/ascorbic acid/calcium

ascorbate, vitamin D/cholecalciferol/ergocalciferol, vitamin E/d/dl-alpha tocopherol/tocopheryl

acetate/tocopheryl succinate, and vitamin K.

Minerals: Boron, calcium, choline, chromium, copper, iodine, iron, magnesium, manganese,

molybdenum, phosphorous, potassium, selenium, and zinc.

Amino acids: Any group of amino acids (e.g. branched chain amino acids) or isolated amino

acids such as alanine, arginine, aspartic acid/asparagine, cysteine/cystine, glutamic

acid/glutamine, glycine, histidine, isoleuine, leucine, lysine, methionine, phenylalanine, proline,

serine, taurine, threonine, tryptophan, tyroisine, and valine.

Herbals/bioactives: caffeine.

Functional foods

Herbals/bioactives: Acai berry/fruit extract, aloe vera leaf (extract), alpha lipoic acid, amla

(extract), aquamin, ashwaganda (extract), astragulus root (extract), bee pollen, bilberry extract,

black cohosh (extract), black tea (extract), bladderwrack, burdock (extract),caffeine, cascara

sagrada, chamomile flower (extract), chasteberry (extract), chlorella, chondroitin sulfate,

citicholine, citrulline malate, coenzyme Q10, coffee bean extract, conjugated linoleic acid

(CLA), elderberry extract, damiana (extract), dandelion extract, dong quai, Echinacea

purpurea/angustifolia/pallida (extract), epimedium/horny goat weed extract, GABA (gamma

amino butyric acid), garcinia cambogia fruit extract/hydroxycitric acid, giant knotweed, ginger

extract, gingko biloba (extract), glucosamine sulfate or hydrochloride, N-acetylglucosamine, goji

berry extract, gotu kola (extract), grape seed/skin extract, grapefruit seed extract, green tea

extract, hibiscus (extract), guarana (extract), gymnema sylvestre leaf (extract), hawthorn, hoodia,

hops, horsetail/equisetum, houblon, kelp, kola nut, lavender (extract), lemon balm/Melissa

(extract), lemon verbena, linden, maca root, mangosteen extract, melatonin, milk thistle

(extract)/silybum/silymarin, MSM/methyl-sulfonyl-methane, noni, North American ginseng

(extract), Panax ginseng (extract)/Korean ginseng/Asian ginseng, passiflora (passionflower),

prickly pear extract, probiotic bacterial cultures, quercitin, raspberry seed extract, red wine

extract, resveratrol, rhodiola (extract), rosehip (extract), rosemary (extract), saw palmetto,

schizandra (extract), skullcap, seabuckthorn, senna, Siberian ginseng (extract)/Eleutherococcus,

spirulina, St. John’s wort, tilleul, uva ursi/bearberry, valerian (extract), vinpocetine, white tea

(extract), white willow bark (extract), yerba mate (extract), 5-hydroxytryptophan

Proteins: Casein, whey, soy, rice, pea protein as concentrates or isolates

96

Omega 3 or omega 6 fats: Fish oil, flax/rapeseed oil, types of fish oil (mackerel, anchovy,

sardine, krill, etc), borage oil, DHA oil, evening primrose oil

Novel fibres: acacia gum (gum arabic), barley bran, beta-glucan, corn bran, corn syrup (fibre),

fructooligosaccharides or oligofructose, galactooligosaccharides, high amylose corn starch,

inulin (from chicory root, Jerusalem artichoke tuber, or Blue agave head),

isomaltooligosaccharides, maltodextrin (fibre), modified wheat starch, oat bran, oat hull fibre,

partially hydrolyzed guar gum, pea hull fibre, polydextrose, polysaccharide complex

(glucomannan, xanthan gum, sodium alginate), psyllium seed husk, sieved barley meal, soy

cotyledon, sugar beet fibre, wheat flakes (starch reduced), wheat bran

Other novel ingredients: plant sterols, phytosterols

* This list was created in collaboration with Health Canada and was based on food ingredients

eligible for consideration for TMALs, as well as ingredients that were commonly found in foods in

FLIP 2013.

97

Appendix 3. List of all supplemented foods (SFs) and ingredients in the FLIP

2013

* RDA/AI/UL refers to highest requirements with the population, excluding pregnant and lactating women and individuals over

the age of 70.

Product Name Company Brand Added ingredient Amount per

serving/ppm

Exceeds

RDA/AI*

Exceeds

UL*

NOS Energy Drink The Coca-Cola

Company

NOS

Taurine 200 mg - -

Caffeine 360 ppm - -

L-theanine 25 mg - -

Vitamin B6 3.96 mg YES -

Vitamin B12 12 µg YES -

Charged Lime

Energy Drink

Coca-Cola

Refreshments

Canada Company

NOS Taurine 200 mg - -

Caffeine 360 ppm - -

L-theanine 25 mg - -

Vitamin B6 3.96 mg YES -

Vitamin B12 12 µg YES -

Super Sours - Green

Apple

Rockstar Inc Rockstar Taurine 2000 mg - -

Caffeine 338 ppm - -

Pantothenic acid 20.3 mg YES -

Niacin 39.1 mg YES YES

Vitamin B6 3.96 mg YES -

Vitamin B12 12 µg YES -

Super Sours –

Bubbleberry

Rockstar Inc Rockstar Taurine 2000 mg - -

Caffeine 338 ppm - -

Pantothenic acid 20.3 mg YES -

Niacin 39.1 mg YES YES

Vitamin B6 3.96 mg YES -

Vitamin B12 12 µg YES -

Energy Drink Red Bull Canada

Ltd.

Red Bull Taurine 1420 mg - -

Caffeine 320 ppm - -

Niacin 27.6 mg YES NO

Pantothenic acid 7 mg YES -

Vitamin B6 7.02 mg YES -

Vitamin B12 7.2 µg YES -

Total Zero Energy

Drink

Red Bull Canada

Ltd

Red Bull Taurine 1000 mg - -

Caffeine 320 ppm - -

Niacin 20.7 mg YES NO

Pantothenic acid 4.9 mg NO -

Vitamin B6 5.04 mg YES -

Vitamin B12 5.0 µg YES -

Sugar Free Energy

Drink

Red Bull Canada

Ltd

Red Bull Taurine 1420 mg - -

Caffeine 320 ppm - -

Niacin 27.6 mg YES NO

Pantothenic acid 7.0 mg YES -

Vitamin B6 7.02 mg YES -

Vitamin B12 7.2 µg YES -

98

Product Name Company Brand Added

ingredient

Amount per

serving/ppm

Exceeds

RDA/AI*

Exceeds

UL*

The Red Edition Red Bull Canada

Ltd

Red Bull Taurine 1000 mg - -

Caffeine 320 ppm - -

Niacin 20.7 mg YES NO

Pantothenic acid 4.9 mg NO -

Vitamin B6 5.04 mg YES -

Vitamin B12 5.0 µg YES -

The Silver Edition Red Bull Canada

Ltd

Red Bull Taurine 1000 mg - -

Caffeine 320 ppm - -

Niacin 20.7 mg YES NO

Pantothenic acid 4.9 mg NO -

Vitamin B6 5.04 mg YES -

Vitamin B12 5.0 µg YES -

The Blue Edition Red Bull Canada

Ltd

Red Bull Taurine 1000 mg - -

Caffeine 320 ppm - -

Niacin 20.7 mg YES NO

Pantothenic acid 4.9 mg NO -

Vitamin B6 5.04 mg YES -

Vitamin B12 5.0 µg YES -

Sugar Free NOS The Coca-Cola

Company

NOS Taurine 200 mg - -

Caffeine 360 ppm - -

Vitamin B6 3.96 mg YES -

Vitamin B12 12 µg YES -

Refreshers - Orange

Melon

Starbucks

Corporation

Starbucks Niacin 5.75 mg NO NO

Pantothenic acid 1.75 mg NO -

Vitamin B6 0.45 mg NO -

Sparkling Green

Coffee – Strawberry

Lemonade

Starbucks

Corporation

Starbucks Niacin 5.75 mg NO NO

Pantothenic acid 1.75 mg NO -

Vitamin B6 0.45 mg NO -

Sparkling Green

Coffee - Raspberry

Pomegranate

Starbucks

Corporation

Starbucks Niacin 5.75 mg NO NO

Pantothenic acid 1.75 mg NO -

Vitamin B6 0.45 mg NO -

Coconut Water All Market, Inc VITA

COCO

Vitamin C 60 mg NO NO

Mocha Cappuccino Bolthouse Juice

Products, LLC

Bolthouse

Farms

Vitamin C 96 mg YES NO

Calcium 330 mg NO NO

Vitamin B6 2.7 mg YES -

Zinc 3.6 mg NO NO

Vitamin B12 9 µg YES -

Pure Life Nature's

Blends Acai Grape

Flavour

Nestle Canada Inc Nestle Zinc 0.9 mg NO NO

Nature's Blends -

Tropical Citrus

Flavour

Nestle Waters

Canada

Nestle Pure

Life

Zinc 0.9 mg NO NO

Enhanced Fruit

Flavoured Water -

Orange Mango

Flavour

Nestle Waters

Canada

Nestle Zinc 0.9 mg NO NO

* RDA/AI/UL refers to highest requirements with the population, excluding pregnant and lactating women and individuals over

the age of 70.

99

Product Name Company Brand Added

ingredient

Amount per

serving/ppm

Exceeds

RDA/AI*

Exceeds

UL*

Fruit Zoo Strawberry

Banana

A. Lassonde Inc Oasis Thiamine 0.13 mg NO -

Folic acid 77 µg NO NO

Iron 1.4 mg NO NO

Grape Wild Berries

Cocktail

A. Lassonde Inc Oasis Thiamine 0.13 mg NO -

Folic acid 77 µg NO NO

Iron 1.4 mg NO NO

Fruit Zoo Apple Juice A. Lassonde Inc Oasis Calcium 88 mg NO NO

Vitamin D 16 IU NO NO

Wild Berry

Pomegranate Juice

A. Lassonde Inc Oasis Nutrisource Vitamin E 2 mg NO NO

Cranberry Juice – Low

Calorie

A. Lassonde Inc Oasis Nutrisource Vitamin E 2 mg NO NO

Cranberry Juice A. Lassonde Inc Oasis Nutrisource Vitamin E 2 mg NO NO

Pomegranate

Blueberry Juice

Beverage with

Vitamins

Tropicana

Products, Inc.

Tropicana

Trop50

Vitamin E 2.5 mg NO NO

Orange Some Pulp

Juice Beverage with

Vitamins

Tropicana

Products, Inc.

Tropicana

Trop50

Magnesium 25 mg NO NO

Thiamine 0.104 mg NO -

Riboflavin 0.096 mg NO -

Vitamin B6 0.108 mg NO -

Apple Juice Loblaws Inc. President Choice-

Blue Menu

Potassium 245 mg NO -

Iron 2.1 mg NO NO

Thiamine 0.195 mg NO -

Folic acid 132 mg NO NO

Strawberry Banana A. Lassonde Inc Oasis Fruit Zoo Potassium 350 mg NO -

Iron 2.1 mg NO NO

Thiamine 0.195 mg NO -

Folic acid 99 mg NO NO

Grape Wild Berries A. Lassonde Inc Oasis Fruit Zoo Potassium 245 mg NO -

Iron 1.4 mg NO NO

Thiamine 0.195 mg NO -

Folic acid 99 mg NO NO

100% Juice - Peach

Clementine

A. Lassonde Inc Oasis - Fruit Zoo Potassium 385 mg NO -

Iron 1.4 mg NO NO

Thiamine 0.195 mg NO -

Folic acid 99 mg NO NO

Pulp Free Orange

Juice

Loblaws Inc. President Choice-

Blue Menu

Thiamine 0.195 mg NO -

Folic acid 66 mg NO -

Trop50 No Pulp

Tropicana

Products, Inc.

Tropicana Magnesium 25 mg NO NO

Thiamine 0.104 mg NO -

Riboflavin 0.096 mg NO -

Vitamin B6 0.108 mg NO -

100

* RDA/AI/UL refers to highest requirements with the population, excluding pregnant and lactating women and

individuals over the age of 70.

Product Name Company Brand Added

ingredient

Amount per

serving/ppm

Exceeds

RDA/AI*

Exceeds

UL*

Trop50 Calcium And

Vitamin D

The Minute Maid

Company Canada

Inc

Tropicana Calcium 330 mg NO NO

Vitamin D 100 IU NO NO

Fruits&Vegetables

Apple-berry

Lassonde Industries

Inc

Oasis Health

Break

Vitamin E 2 mg NO NO

Orange Juice - 100%

Pure - with calcium &

vitamin D

Canada Safeway

Limited

Safeway

Select

Calcium 330 mg NO NO

Vitamin D 120 IU NO NO

100% Pure & Natural

Orange Juice With

Added Calcium And

Vitamin D - no pulp

Tropicana Products,

Inc.

Tropicana

Essentials

Calcium 330 mg NO NO

Vitamin D 100 IU NO NO

Orange Juice With

Added Calcium And

Vitamin D

Loblaws Inc.

President

Choice-Blue

Menu

Calcium 330 mg NO NO

Vitamin D 100 IU NO NO

100% Apple juice A. Lassonde Inc Oasis

Classic

Calcium 110 mg NO NO

Vitamin D 20 IU NO NO

Orange Juice Metro Brand Irresistibles -

life smart

Calcium 330 mg NO NO

Vitamin D 100 IU NO NO

Minutes Maid

Calcium And Vitamin

D 100% Orange Juice

Frozen Concentrate

The Minute Maid

Company Canada

Inc

Minute Maid

Calcium 330 mg NO NO

Vitamin D 100 IU NO NO

Simply Orange

Calcium

The Minute Maid

Company Canada

Inc

Simply

Orange

Calcium 330 mg NO NO

100% pure & natural

orange juice with

added calcium +

Vitamin D

Tropicana Products,

Inc.

Tropicana

Essentials

Calcium 330 mg NO NO

Vitamin D 100 IU NO NO

Cheddar Style

Flavour

Galaxy Nutritional

Foods

Veggie Vitamin A 300 RE NO NO

Vitamin B12 1.5 µg NO -

Vitamin D 100 IU NO NO

Folic acid 99 µg NO NO

Vitamin B6 0.54 mg NO -

Vitamin E 7.5 mg NO NO

Italian Flavour Galaxy Nutritional

Foods

Veggie Vitamin A 300 RE NO NO

Vitamin B12 1.5 µg NO -

Vitamin D 100 IU NO NO

Folic acid 99 µg NO NO

Vitamin B6 0.54 mg NO -

Vitamin E 7.5 mg NO NO

101

Product Name Company Brand Added

ingredient

Amount per

serving/ppm

Exceeds

RDA/AI*

Exceeds

UL*

Malt Drink Mix -

Chocolate

AB Food and

Beverages

(Thailand) Ltd

Ovaltine

Vitamin C 15 mg NO NO

Vitamin A 250 RE NO NO

Iron 2.8 mg NO NO

Niacin 4.6 mg NO NO

Ovaltine - Classic Nestle Canada Inc. Ovaltine Vitamin C 18 mg NO NO

Vitamin A 250 RE NO NO

Iron 3.5 mg NO NO

Niacin 3.45 mg NO NO

Thiamine 0.325 mg NO -

Gluten-Free Corn &

Rice Flakes

Glutino Foods Glutino Vitamin E 7 mg NO NO

Vitamin B6 0.72 mg NO -

Folic acid 154 µg NO NO

Vitamin B12 3.2 µg YES -

V8 Low-Sodium

Vegetable Cocktail

Campbell Company

of Canada

V8 Potassium 840 mg NO -

Garden Cocktail -

Original Low Sodium

Canada Dry Mott's

Inc.

Mott's Potassium 700 mg NO -

Garden Cocktail

Low-Sodium

Canada Dry Mott's

Inc.

Mott's Potassium 455 mg NO -

Low-Sodium

Vegetable Cocktail

Campbell Company

of Canada

V8 – V

Fusion

Potassium 525 mg NO -

* RDA/AI/UL refers to highest requirements with the population, excluding pregnant and lactating women and

individuals over the age of 70.

102

Appendix 4. Standardized method used to calculate FSANZ nutrient profiling

score (NPSC) using data in the Canadian FLIP 2013 database

Step 1: Classify food into NPSC category

Category 1: Beverages

Category 2: Foods not included in Categories 1 or 3

Category 3: Cheese (with calcium content >320 mg/100 g), edible oil, edible oil spreads,

margarine, butter

Step 2: Calculate baseline points for average nutrient content/100 g or 100 mL

0 – 10 points for energy (kJ)

0 – 30 points for saturated fat (g)

0 – 10 points for total sugars (g)

0 – 30 points for sodium (mg)

Total baseline points = (energy points) + (saturated fat points) + (total sugars points) + (sodium

points)

Step 3: Calculate points for fibre (F), protein (P), and fruit/vegetable/nut/legume content (V) per

100 g or 100 mL

0 – 5 points for fibre (g)

0 – 5 points for protein (g)

0 – 5 points for fruit/vegetable/nut/legume (%)

Final score = Total baseline points – F points – P points – V points

Component of NPSC Information Available from Canadian Food

Labels

Energy (kJ/100 g or 100 mL) From Nutrition Facts table (NFt)

● kcal values converted to kJ

Saturated Fat (g/100 g or 100 mL) From Nutrition Facts table (NFt)

Total sugars (g/100 g or 100 mL) From Nutrition Facts table (NFt)

Sodium (mg/100 g or 100 mL) From Nutrition Facts table (NFt)

Fibre (g/100 g or 100 mL) From Nutrition Facts table (NFt)

Protein (g/100 g or 100 mL) From Nutrition Facts table (NFt)

Fruit/vegetable/nut/legume (FVNL) (%) Not available

● FVNL content estimated from rank of FVNL

ingredients in Ingredients List (see Appendix 1

for method of calculation in FLIP 2013)